Industrial Parkway London / West Sacramento / Sacramento / /
Company
Authorized / /
Country
United States / / /
Facility
Mail Station / /
IndustryTerm
online account / health services / health insurance / law enforcement action / insurance affordability programs / insurance affordability program / /
Organization
Social Security Administration / CA Department of Social Services Attn / Internal Revenue Service / State Hearings Division / California Department of Social Services / Department of Homeland Security / United States Department of Health and Human Services / Social Service’s Affordable Care Act Bureau / County Welfare Department / CDSS’s State Hearings Division / Medicare / /
Person
Law Judge / QUAN TR / Covered California / Form (optional) Assistance / / /
Request for a State Fair Hearing to Appeal a Covered California Eligibility Determination If you need help in another language, or would like this form in another language, please refer to the last page of this docum