Get Request To Amend Personal Information - Covered California

The Request To Amend Personal Information - Covered California form allows individuals to request changes to their personal records maintained by Covered California. This guide provides clear, step-by-step instructions on how to fill out this form online, ensuring that your request is submitted accurately and efficiently.

Follow the steps to successfully complete your request to amend personal information.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editing tool.
2. Begin with the consumer information section. Fill in your last name, first name, and middle initial as they appear on your Covered California account. Enter your address, including city, state, and zip code.
3. Provide your Covered California case or account number, daytime phone number, date of birth, and email address in the designated fields.
4. Clearly indicate what personal information you wish to amend and provide a brief explanation of why you want it amended.
5. In the ‘What should the record state?’ section, specify what the corrected information should indicate.
6. For address verification, attach a copy of a valid document showing your name and current address, such as a California driver’s license or a utility bill.
7. For identity verification, include a copy of an identifying document like a California driver’s license or notify the document must be notarized if no identification is attached.
8. If notarization is required, ensure you provide the date notarized, the notary’s information, and their signature.
9. Sign and date the form to confirm that the information provided is accurate and truthful.
10. Once you have completed the form, save your changes. You can then download, print, or share the form as needed.

Complete your Request To Amend Personal Information form online today to ensure your records are accurate and up-to-date.