Marketplace Employer Appeal Request Form - U.s. Centers For Medicare And Medicaid Services Page 3
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Employer Appeal Request Form
Form Approved
OMB No. 0938-1213
Use this form to appeal a Marketplace determination that an employee was eligible for advance payments
Appeal Request Form – Employer
of the premium tax credit and cost-sharing reductions (if applicable) in part because your business didn’t
offer health coverage that met minimum value requirements and was affordable with respect to this employee.
Enter your information directly, then print and sign your completed form. Or, print a blank form to fill in using
black or dark blue ink. Use capital letters.
SECTION 1:
Tell us about the employer who’s requesting this appeal.
1. Business Name
Federal Employer ID Number (EIN)
Business phone number
Primary business mailing address
Suite #
City
State
ZIP code
Name of the primary contact (First name)
(Middle Name)
(Last name)
Primary contact phone number
Primary contact mailing address
Suite #
City
State
ZIP code
Title of primary contact
SECTION 2:
Designate a secondary contact. (optional)
This is someone who may act on your organization’s behalf regarding this appeal request.
Name of the secondary contact (First name)
(Middle Name)
(Last name)
Secondary contact phone number
Organization name (if applicable)
Title of secondary contact
Secondary contact mailing address
Suite #
City
State
ZIP code
Marketplace Appeal Request From – Employer (08/2017)
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