Get Hbex 411b 2018-2025

Filling out the HBEX 411b form is an important process for reporting the death of an enrolled member in the California Health Benefit Exchange. This guide will provide clear, step-by-step instructions to assist you in completing the form online efficiently and accurately.

Follow the steps to complete the HBEX 411b form online.

1. Click the ‘Get Form’ button to access the HBEX 411b form and open it in your preferred editor.
2. Begin by entering the deceased consumer’s information. Fill out their first name, last name, middle initial, address, city/state, zip code, date of birth, and the date of death as indicated on their Covered California account.
3. Next, provide your information as the reporting member. Include your first name, last name, middle initial, address, city/state, zip code, required daytime phone number, and email address.
4. Indicate your relationship to the deceased by selecting the appropriate option.
5. Answer the questions regarding the need for a copy of the previous year’s IRS form 1095A and whether the address on the account needs to be updated. If updating, provide the new address, including city/state and zip code.
6. Attach a copy of the reporting member’s identifying information, or ensure your signature is notarized if no identifying document is attached. Include the relevant identification details.
7. Sign and date the form to confirm the information is truthful and accurate, acknowledging that Covered California may be unable to comply with your request but will respond accordingly.
8. Review all the information you have entered for accuracy, then save your changes, download the completed form, print it, or share it as needed.

Complete your HBEX 411b form online today to ensure prompt processing of your request.