PRIVACY COMPLAINT BY A PARENT, GUARDIAN, OR AUTHORIZED REPRESENTATIVE
HBEX 406 (8/15)
Please select one of the following options. (Please note, not using your name may hinder Covered
California’s ability to resolve your complaint.)
I consent to my name being disclosed in order to resolve this complaint.
I do not consent to my name being disclosed.
Please provide details of your complaint (If necessary, attach a separate page):
I understand Covered California may not be able to comply with my request, but will respond to my request.
I declare under penalty of perjury that the information on this form is true and correct.
The information requested on this form is required by the California Health Benefits Exchange, Privacy
Office in order to process your request. The information you provide on this form is required to process your
request and will be used by the Privacy Office for that purpose. Failure to provide this information may
result in the denial of your request. Legal references authorizing the collection or maintenance of the
information provided on this form include Sections 1798.22, 1798.25, 1798.27 and 1798.35 of the California
Civil Code and Section 155.260(a) of the Code of Federal Regulations. California Health Benefits
Exchange, Privacy Office, 1601 Exposition Blvd, Sacramento, CA 95815 (800) 889-3871.