Fillable REQUEST TO AMEND PERSONAL INFORMATION HBEX 409 (8/15) (Covered California)

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REQUEST TO AMEND PERSONAL INFORMATION HBEX 409 (8/15) (Covered California)

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The REQUEST TO AMEND PERSONAL INFORMATION HBEX 409 (8/15) (Covered California) form is 2 pages long and contains:

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  • 7 check-boxes
  • 12 other fields

Country of origin: US
File type: PDF

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STATE OF CALIFORNIA
CALIFORNIA HEALTH BENEFIT EXCHANGE/COVERED CALIFORNIA (Exchange/CC)
REQUEST TO AMEND PERSONAL INFORMATION
HBEX 409 (8/15)
Request to Amend Personal Information
You have the right to request amendments to the records Covered California creates or maintains about you.
We will act upon your request within 30 days of our receipt of your request. If your request is denied, we will
let you know the reasons for the denial in writing. Should we deny your request, you have the right to request
a review of our decision and we will provide you the name and contact information of the reviewing official in
conjunction with a written copy of our decision. Please complete this form and attach all relevant documents.
You may submit the form and documents by either mail or fax.
Covered California
P.O. Box 989725
West Sacramento, CA 95798-9725
Fax: (888) 329-3700
Consumer Information
(As indicated on your Covered California Account)
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Covered California Case or Account Number:
Date of Birth:
Daytime Phone Number:
Email Address
What personal information do you want to amend? Why do you want it amended?
REQUEST TO AMEND PERSONAL INFORMATION
HBEX 409 (8/15)
Page 2
What should the record state?
Address Verification
(Please attached a copy of one of the following with your name and current address.)
California Driver’s License
Utility Bill
Other
Identity Verification
(Please attached a copy of one of the following. If no identifying document is attached, your signature must
be notarized.)
California Driver’s License
State of California Identification Card
Federal Issued I.D. Card
Notary
Date Notarized:
UNOFFICIAL UNLESS STAMPED BY NOTARY
PUBLIC
Notarized By:
Notary Public Number:
Signature
I understand Covered California may not be able to comply with my request but will provide me with a response.
I declare under penalty of perjury that the information on this form is true and correct.
Signature:
Date:
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.
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REQUEST TO AMEND PERSONAL INFORMATION HBEX 409 (815) (Covered California)

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Completed 19 May 2021

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