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Documentation Samples

Listed below are samples of documentation you will need to fill out forms or send to us for proof of your Marketplace plan.

Premium Bill Samples

Healthcare.gov Sample

Go to your healthcare.gov account and go to “My Plans &Programs”.

Moda Premium Bill Sample

Pacific Source Premium Bill Sample

Kaiser Permanente Premium Bill Sample

Regence Premium Bill Sample

Providence Premium Bill Sample

Marketplace Eligibility Notice Samples

Not Eligible for APTC (married, filing, filing separate tax returns)

Eligible to enroll with financial help, must send documents

Medicaid assessment

Eligible to enroll with financial help

For more information

Visit these pages to learn more about your benefits and how to use them if you are eligible:
Forms Webpage
Healthcare Cost Assistance Webpage
FAQs Webpage
MyCarewell503

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