There is NO COST FOR THIS SERVICE. The purpose of this form is to assist you to swiftly retrieve your Covered California 1095-A so you can file your taxes timely. Generally we aim to obtain this within 2 hours of your request but there are circumstances that require us to contact you by telephone in order to retrieve your Covered California 1095-A. After we have retrieved your requested 1095-A we will remit this to you by means of email. Information that we will require to obtain your 1095-A:

1. First and Last Name
2. Date of Birth
3. Your address on file with Covered California
4. Your Phone Number that is listed on Covered California (if applicable)
5. Your Email Address