DEPARTMENT OF HEALTH AND HUMAN SERVICES

465 INDUSTRIAL BOULEVARD

LONDON, KENTUCKY 40750-0001

Floyd Mitchell Aug 16, 2021

100 EASTBROOK sta
APT 32
Harlan, KY 40831

Dear Floyd:

We need more information before you can complete an application for the Marketplace

You’re getting this message because you attempted to complete an application for health coverage or
designate an authorized representative through the Health Insurance Marketplace. For privacy and security
reasons, the Marketplace is unable to process your application, and you need to provide documentation in
order to complete your application. Please send a copy of one of the following documents that shows Floyd
Mitchell’s information to the Marketplace:

• Driver’s license issued by state or territory

• School identification card
• Voter registration card
• U.S. military card or draft record
• Identification card issued by the federal, state, or local government, such as
• U.S. passport or U.S. passport card
• Certificate of Naturalization (Form N-550 or N-570) or Certificate of U.S. Citizenship (Form
N-560 or N-561)
• Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
• Employment Authorization Document that contains a photograph (Form I-766)
• Military dependent’s identification card
• Native American Tribal document
• U.S. Coast Guard Merchant Mariner card
• Foreign passport, or identification card issued by a foreign embassy or consulate that contains a
photograph

If you can’t provide a copy of one of the above documents, you can instead submit copies of two of the

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following documents:

• Birth certificate
• Social Security card
• Marriage certificate
• Divorce decree
• Employer identification card
• High school or college diploma (including high school equivalency diplomas)
• Property deed or title

Please don’t submit original documents. The document(s) provided must have either a photograph or other
identifying information such as name, age, sex, race, height, weight, eye color, or address. The Marketplace
may ask you additional questions regarding your documentation in order to verify your identity.

Send a copy of your document or documents electronically to the Marketplace by logging into your
Marketplace account and uploading a copy of the document or mail it to:

Health Insurance Marketplace

Department of Health and Human Services
465 Industrial Boulevard
London, Kentucky 40750-0001

Where can I find more information?

Visit us online at HealthCare.gov. Or, call 1-800-318-2596 (TTY: 1-855-889-4325).

Sincerely,

Health Insurance Marketplace

Department of Health and Human Services
465 Industrial Boulevard
London, Kentucky 40750-0001

Privacy Disclosure: The Health Insurance Marketplace protects the privacy and security of the personally identifiable information (PII) that you have
provided (see Healthcare.gov/privacy/). This notice was generated by the Marketplace based on 45 CFR 155.230 and other provisions of 45 CFR
part 155, subpart D. The PII used to create this notice was collected from information you provided to the Health Insurance Marketplace. The
Marketplace may have used data from other federal or state agencies or a consumer reporting agency to determine eligibility for the individuals on
your application. If you have questions about this data, contact the Marketplace at 1-800-318-2596 (TTY: 1-855-889-4325).

You can also call the Marketplace call center to get information from this notice in your language, or request a reasonable accommodation if you
have a disability. You can ask for information in an accessible format, like large print, Braille, or audio at no cost.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1207.

Nondiscrimination: The Health Insurance Marketplace doesn't exclude, deny benefits to, or otherwise discriminate against any person on the basis

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of race, color, national origin, disability, sex, or age. If you think you've been discriminated against or treated unfairly for any of these reasons, you
can file a complaint with the Department of Health and Human Services, Office for Civil Rights by calling 1-800-368-1019 (TTY: 1-800-537-7697),
visiting hhs.gov/ocr/civilrights/complaints, or writing to the Office for Civil Rights/ U.S. Department of Health and Human Services/ 200
Independence Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.

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Important: If you mail in your documentation, please also include this page in the same envelope, which
includes a barcode, along with any documents. This page helps the Marketplace make sure your documents
can easily be associated with your application.

7c4e85c8-a50d-4e4d-9dbb-2e9a22751111

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January 2019
January 2019