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.