Covered California compares the information you enter on your application with government data sources or information you've provided before. If the data is inconsistent, we ask you to submit documents to confirm the new information. 

Proof of Social Security Number (SSN)

Submit a copy of one of the following documents.

1. Your Social Security card.

2. Tax form(s).

3. Benefit or income statement from Social Security containing the Social Security number.

4. Pending application for an SSN.

5. Letter from the Social Security Administration stating that the applicant is not eligible for an SSN or is only eligible for a non-work SSN.

6. Letter stating that the applicant refuses to obtain an SSN for established religious objections (SSN Waiver).

Proof of Identity

Submit a copy of one of the following documents.

1. Driver’s license issued by a state or territory showing either a photograph of the individual and/or other identifying information of the individual such as name, age, sex, race, height, weight or eye color.

2. School identification card that includes a photograph.

3. Voter Registration Card.

4. U.S. Military card, draft record or Military dependent’s identification card.

5. Identification card issued by the federal, state, or local government that contains a photograph.

6. U.S. or foreign passport, U.S. passport card (expired passport may be used) or identification card issued by a foreign embassy or consulate that contains a photograph.

7. Certificate of Naturalization (Form N-550 or N-570) or Certificate of U.S. Citizenship (Form N-560 or N-561).

8. Permanent Resident Card or Alien Registration Receipt Card (Form I-551).

9. Employment Authorization Document that contains a photograph (Form I-766).

10. Native American tribal document with photograph.

11. For children under the age of 16:

    • A clinic, doctor, hospital, or school record.

    • In the absence of the previous, a written statement signed under penalty of perjury by the parents or guardian stating date and place of birth (cannot be used in conjunction with a citizenship affidavit).

12. U.S. Coast Guard Merchant Mariner card.

13. Finding of identity from a federal agency or state government agency including but not limited to public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, if the agency has verified and certified the identity of the individual.

Instructions on how submit documents can be found on the Submit Documents to Confirm Your Eligibility page.

If you cannot provide a copy of any of the identity documents listed above, you must provide copies of two of the following documents:

1. Birth certificate.

2. Social Security card.

3. Marriage certificate.

4. Divorce decree.

5. Employer identification card.

6. High school or college diploma (including high school equivalency diplomas).

7. Property deed or title document.

8. Adoption decree.

9. Foreign school record that contains a photograph.

10. Notice from public benefits agency.

11. Union or worker’s center identification card.

Proof of Citizenship or U.S. National Status

Submit a copy of one of the following documents.

Primary (Stand-Alone) Evidence of Citizenship

1. U.S. Passport or U.S. Passport Card, current or expired (issued without limitation).

2. Certificate of U.S. Citizenship.

   • Form N-560.

   • Form N-561.

3. Certificate of Naturalization.

   • Forms N-550, N-570.

4. Documentary evidence issued by a federally recognized American Indian or Alaska Native tribe. Documents must identify the individual by name and confirm the individual’s membership, enrollment, or affiliation with a tribe. Documents include but are not limited to:

   • Tribal enrollment card.

   • Certificate of Degree of Indian Blood.

   • Tribal census document.

   • Documents on Tribal letterhead, issued under the signature of the appropriate Tribal official.

Secondary evidence of citizenship

If you do not have any of the above primary (standalone) evidence, provide copies of two documents (secondary evidence): one from List A and one from List B.

    List A

1. U.S. Public Birth Certificate.

2. Consular Report or Certificate of Child Born Abroad.

   • Department of State Form FS-545.

   • Department of State Form FS-240.

   • Department of State Form DS-1350.

3. Individual Fee Register receipt (INS Form G-711).

4. U.S. citizen identification card (I-197 or the prior version I-179).

5. Federal or State census record showing U.S. citizenship or U.S. place of birth.

6. A Northern Mariana Identification Card issued to a collectively naturalized citizen, who was born in the CNMI before Nov. 4, 1986 (I-873).

7. Adoption Decree.

   • A final adoption decree showing the child’s name and U.S. place of birth; or

   • If the adoption is not finalized, a statement from a state-approved adoption agency that shows the child’s name, U.S. place of birth, and birthdate or age (the adoption agency must state in the certification that the source of the place of birth information is an original birth certificate).

8. Documentation of a foreign-born child (including a foreign-born adopted child) who received automatic U.S. citizenship through (IR3 or IH3) or the Child Citizenship Act. Documentation must clearly show the child’s name and date of birth.

9. U.S. military records showing a U.S. place of birth.

10. Evidence of U.S. Civil Service employment before June 1, 1976.

11. U.S. medical records, including but not limited to hospital, clinic, midwife, or physician records or admission papers from a nursing facility, skilled care facility, or other institution. Records must:

    • Indicate U.S. place of birth.

    • Be signed and on hospital letterhead.

    • Be established at the time of the person's birth.

12. U.S. insurance records showing a U.S. place of birth. Records must:

    • Indicate U.S. place of birth.

    • Be created at least five years before the initial Covered California application date, unless the applicant is under the age of five.

13. Official religious records recorded in the U.S. Records must:

    • Be created within three months of birth.

    • Indicate U.S. place of birth.

    • Indicate the date of the birth or the individual's age at the time the record was made.

    • Be an official record recorded with the religious organization.

14. School records including pre-school, Head Start, and daycare records. Records must:

    • Indicate the child’s name.

    List B

1. Driver's license issued by a State or Territory, or ID card issued by the federal, state, or local government.

2. School identification card.

3. U.S. military card or draft record or Military dependent’s identification card.

4. U.S. Coast Guard Merchant Mariner card.

5. A clinic, doctor, hospital, or school record, including preschool or day care records (for children under 19 years old).

6. Two documents containing consistent information that proves the applicant’s identity, such as:

   • 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 document.

Note: Immigrants who are not lawfully present do not qualify for a health plan through Covered California; however, they may qualify for coverage through Medi-Cal up to age 26 or for pregnancy coverage. Immigrants who are not lawfully present can also buy private health insurance on their own outside of Covered California. Additionally, some counties offer other health care options for immigrants who are not lawfully present. To apply for coverage, call (800) 300-1506 or apply with a certified enroller or your county. Get information on applying for Medi-Cal.

Proof of Immigration Status or Lawful Presence

Immigrants who are not lawfully present do not qualify for a health plan through Covered California; however, they may qualify for coverage through Medi-Cal if they are younger than age 26 or are 50 or older, or are pregnant or were recently pregnant. Immigrants who are not lawfully present can also buy private health insurance on their own outside of Covered California. Additionally, some counties offer other health care options for immigrants who are not lawfully present. To apply for coverage, call (800) 300-1506 or apply with a certified enroller or your county. Get information on applying for Medi-Cal.

Submit a copy of one of the following documents.

1. Lawful permanent residents (LPR/green card holder). For pending applicants for adjustment to LPR, go to #22 of this section.

   • Permanent Resident Card or “Green Card” (I-551).

   • Temporary I-551 stamp on form I-94/I-94A or on a foreign passport.

   • Machine Readable Immigrant Visa with temporary I-551 language.

   • Reentry Permit (I-327).

   • Arrival/Departure Record (I-94) (showing stamp for admission as LPR).

   • Arrival/Departure Record (I-94) in foreign passport (showing stamp for admission as LPR).

   • Order issued by Department of Homeland Security (DHS), Board of Immigration Appeals, or Immigration Judge granting registry, suspension of deportation, cancellation of removal, or adjustment of status.

   • Receipt from U.S. Customs and Immigration Service (USCIS) showing that Form I-90, application for LPR replacement card, has been filed.

2. Asylees. For pending applicants for Asylum, go to #23 of this section.

   • Arrival/Departure Record (I-94) (with stamp showing grant of asylum, “Asylee” or “§208”).

   • Arrival/Departure Record (I-94) in foreign passport (with stamp showing grant of asylum, “Asylee” or “§208”).

   • Order granting asylum by USCIS, DHS, immigration judge, Board of Immigration Appeals, or federal court.

   • Employment Authorization Document (Card) (I-766) (annotated “A5”).

   • Refugee Travel Document (I-571).

   • Permanent Resident Card, “Green Card” (I-551).

3. Refugees

   • Arrival/Departure Record (I-94/I-94A) (stamped “Refugee” or “§207”).

   • Employment Authorization Document (Card) (I-766) (annotated “A3”).

   • Refugee Travel Document (I-571).

   • Permanent Resident Card, “Green Card” (I-551).

   • Application for Employment Authorization (I-765), or receipt from USCIS indicating filing of application.

4. Conditional entrant (CE) granted before 1980 (Note: this is the immigration status used for refugees prior to the Refugee Act of 1980; most have adjusted to LPRs though some retain CE status.)

   • Arrival/Departure Record (I-94/I-94A) (indicating status as “conditional entrant,” “refugee-conditional entrant,” “Seventh Preference,” “§203(a)(7)” or “P7”).

   • Employment Authorization Document (Card) (I-766) (annotated “A3”).

   • Permanent Resident Card or “Green Card” (I-551).

5. Individuals granted withholding of deportation or withholding of removal (under the immigration laws or under the Convention Against Torture [CAT])For pending applicants for withholding of deportation/ removal, go to #23 of this section.

   • Document indicating withholding of removal (e.g., an order granting withholding of deportation/removal issued by USCIS, DHS, immigration judge, Board of Immigration Appeals, or federal court).

   • Employment Authorization Document (Card) (I-766) (annotated “A10”).

   • Administrative order staying removal issued by the Department of Homeland Security.

   • Arrival/Departure Record (I-94/I-94A) (stamped “Withholding of Deportation,” “§243(h)” or “§241(b)(3)”).

   • Refugee Travel Document (I-571).

6. Individuals paroled into the U.S.

   • Arrival/Departure Record (I-94/I-94A) (with stamp indicating “parole” or “PIP” or “212(d)(5)” or other language indicating parole status).

   • Employment Authorization Document (Card) (I-766) (annotated “A4” or “C11”).

   • Employment Authorization and Advance Parole Card (I-512) (annotated with reason parole was granted under Title 8 of the Code of Federal Regulations).

7. Cuban or Haitian Entrants

   • Arrival/Departure Record (I-94/I-94A) (with stamp indicating “Cuban/Haitian Entrant” or any other notation indicating “parole under §212(d)(5)”, including “CU6,” “CU7,” or “CH6,” among others – rare since 1980s).

   • Employment Authorization Document (Card) (I-766) (annotated “C8,” or “C11”).

   • Temporary I-551 Stamp (on passport or I-94/I-94A).

   • Permanent Resident Card, “Green Card” (I-551).

   • Receipt or notice showing filing or pending status of Application for Asylum and withholding (I-589).

8. Qualified Domestic Violence Survivor (the parent and/or child of a spouse or child who has been battered or subjected to extreme cruelty in the U.S. by a spouse, parent, or relative of the same household) who has been approved (or has a pending petition) under Violence Against Women Act (VAWA) for (1) status as a spouse or a child of a U.S. citizen, (2) status as a spouse or a child of a U.S. lawful permanent resident, (3) suspension of deportation, or (4) cancellation of removal.

   • Application to qualify as abused spouse, child, or parent under VAWA (I-360).

   • Notice of Action (I-797) (referencing a pending “I-360”).

   • Employment Authorization Document (Card) (I-766) (annotated “A10,” “C14,” “C9,” “C10,” “C14” or “C31”).

   • Receipt or other proof of filing I-485 “Application to Register Permanent Residence or Adjust Status.”

   • Any documents indicating a pending suspension of deportation or cancellation of removal case, including a receipt from an immigration court indicating filing of Application for Suspension of Deportation (EOIR-40) or Application for Cancellation of Removal (EOIR-42).

   • Receipt or other proof of filing I-130 visa petition under immediate relative (IR) or second family preference (P-2) showing status as a spouse or child.

9. Victim of Trafficking and his/her Spouse, Child, Sibling or Parent (or individuals with a pending application for a victim of trafficking visa).

   • Certification from Office of Refugee Resettlement (ORR).

   • ORR eligibility letter if under 18 years of age.

   • Employment Authorization Document (Card) (I-766) (annotated “A16,” “C25”).

   • Notice of Action (I-797) ( “Approval Notice” for “CP,” “T-1”or “extension of T or U non-immigrant status”, “T-2 spouse,” “T-3 child,” “T-4 parent,” “T-5 unmarried sibling under 18.”).

   • Permanent Resident Card, “Green Card” (I-551).

   • Employment Authorization and Advance Parole Card (I-512) (authorization for parole, indicating “T-2,” “T-3,” “T-4,” “T-5,”status).

   • T-Visa Application (I-914).

   • Certification status verified through U.S. Department of Health and Human Services. Trafficking Verification Line: (866)-401-5510.

10. Member of a federally recognized Indian tribe or American Indian born in Canada

    • Certificate from Department of Interior or Department of Indigenous and Northern Affairs certifying Native American tribal ancestry or other authoritative document.

    • Letter from the Canadian Department of Indian Affairs, birth or baptismal record issued on a Canadian Indian Reservation, or tribal or school records which establish that American Indians born in Canada are of at least one half American Indian ancestry.

11. Other Non-Immigrant Status (letter visas) including worker visas and student visas:

    • F-1, F-2, M1 and M2 (academic and student non-immigrant visa categories).

      • Form I-20.

      • Arrival/Departure Record (I-94/I-94A) showing non-immigrant status.

      • Foreign Passport (indicating admission to U.S. with non-immigrant visa).

      • Employment Authorization Document (Card) (I-766) (indicating non-immigrant status).

    • J-1 and J-2 (exchange visitors including professors, scholars and physicians non-immigrant visa categories).

      • Form DS-2019, Certificate of Eligibility for Exchange Visitor Status.

      • Arrival/Departure Record (I-94/I-94A) indicating non-immigrant status.

      • Foreign Passport (with admission stamp indicating admission to U.S. with non-immigrant visa).

      • I-797, Notice of Action.

      • Employment Authorization Document (Card) (I-766) (indicating non-immigrant status).

    • H, L, O, P, Q (temporary worker non-immigrant visas categories).

      • Foreign passport (indicating admission to U.S. with non-immigrant visa).

      • Arrival/Departure Record (I-94/I-94A) indicating non-immigrant status.

      • Form I-797, Notice of Action.

      • Employment Authorization Document (Card) (I-766) (indicating non-immigrant status).

    • T (victim of human trafficking non-immigrant visa category).

      • Foreign passport (admission stamp indicating admission to U.S. with non-immigrant visa).

      • I-797, Notice of Action for “T” Status.

      • Arrival/Departure Record (I-94/I-94A) indicating non-immigrant visa status.

      • Employment Authorization Document (Card) (I-766) (indicating non-immigrant status).

      • Form I-485, Adjustment of Status.

    • U (victim of criminal activity non-immigrant visa category).

      • Foreign passport (admission stamp indicating admission to U.S. with non-immigrant visa).

      • Arrival/Departure Record (I-94/I-94A) indicating “U” non-immigrant visa.

      • Receipt of Form I-918.

      • Employment Authorization Document (Card) (I-766) (indicating non-immigrant status).

      • Form I-539, Application to Extend Non-immigrant Status.

      • Form I-485, Adjustment of Status.

    • All other valid non-immigrant Letter Visa categories.

      • Valid non-immigrant visas begin with the letters A through V (however, most non-immigrant visas will be identified in the worker, visitor, and student visa types above).

      • Including but not limited to A, K, and R visas.

      • Foreign passport (admission stamp indicating admission to U.S. with non-immigrant visa).

      • Employment Authorization Document (Card) (I-766) (indicating non-immigrant status).

      • Arrival/Departure Record (I-94/I-94A) indicating admission to the US with a non-immigrant visa.

      • Form I-539, Application to Extend Non-immigrant Status.

12. Citizens of Micronesia, the Marshall Islands, and Palau

    • Arrival/Departure Record (I-94/I-94A).

    • Foreign Passport (annotated “CFA/RMI,” “CFA/FSM” or “CFA/PAL.”

    • Employment Authorization Document (Card) (I-766) (annotated “A8”).

13. Residents of American Samoa

    • An official document showing the individual is a resident of, or lives in, American Samoa.

14. Lawful Temporary Residents

    • Employment Authorization Document (Card) (I-766) (annotated “A2”, or with other evidence indicating eligibility under “§210” or “§245A”).

    • Application to Adjust from Temporary to Permanent Residence under INA §245A (I-698).

15. Individuals with Temporary Protected Status (TPS). For pending applicants for TPS, go to #23 of this section.

    • Employment Authorization Document (Card) (I-766) (annotated “A12”).

    • Notice of Action (I-797) (showing grant of TPS status).

16. Individuals granted Deferred Enforced Departure (DED)

    • Employment Authorization Document (Card)(I-766) (annotated “A11”).

    • Immigration documentation with an alien number or I-94 showing status.

17. Individuals granted Deferred Action Status

    • Notice of Action (I-797) (showing approval of “deferred action” status).

    • Employment Authorization Document (Card) (I-766) (annotated “C14”).

18. Note: Deferred Action for Childhood Arrivals (DACA) is not an eligible immigration status for health insurance through Covered California. The Employment Authorization Document (I-766) annotated Category “C33” is specific to DACA and is not proof of eligibility for Covered California. Individuals with DACA status may be eligible for Medi-Cal.

19. Family Unity beneficiaries

    • Notice of Action (I-797) (showing approval for “Application for Family Unity [I-817]”).

    • Employment Authorization Document (Card) (I-766) (annotated “A13”).

20. Individuals with Order of Supervision with employment authorization

    • Notice or form showing release under “Order of Supervision” and Employment Authorization Document (Card) (I-766).

21. Registry applicants with employment authorization

    • Receipt or notice showing filing Form I-485 “Application to Register Permanent Residence or Adjust Status” and Employment Authorization Document (Card) (I-766).

22. Applicant for Special Immigrant Juvenile Status

    • Notice of Action (I-797) (“Special Immigrant Juvenile Approval Notice,” “Welcome Notice/Approval of I-485,” or “Other Basis of Adjustment SL6”).

    • Permanent Resident Card, “Green Card” (I-551) (coded “SL6”).

23. Applicant for Adjustment to LPR Status

    • Notice of Action (I-797) (ASC Appointment notice with Case Type “I-485 Application” and “Receipt of Application for Employment Authorization based on C9”).

    • Employment Authorization Document (Card) (I-766) (e.g. annotated “C9” or “C9P”).

    • Employment Authorization and Advance Parole Card (I-512) (authorization for parole, indicating applicant for adjustment of status).

    • Receipt showing filing or pending status of Form I-485 “Application to Register Permanent Residence or Adjust Status.”

24. Applicants for any of the following statuses must also submit an Employment Authorization Document (Card) (I-766).

    • Temporary Protected Status (TPS) with employment authorization.

      • Receipt or notice showing filing or pending status of “Application for Temporary Protected Status” (I-821) and Employment Authorization Document (Card) (I-766) (annotated “C19”).

    • Legalization under IRCA or the LIFE Act with employment authorization.

      • Foreign passport (with a stamp or writing by INS/DHS officer, indicating pending “§245A Application”) and Employment Authorization Document (Card)(I-766) (annotated “Application for Temporary Residence under INA §245A” [I-687]).

    • Asylum or Withholding of Deportation/Removal, including applicants under the Convention against Torture (CAT) (only if granted employment authorization or are under the age of 14 and have had an application pending for at least 180 days).

      • Receipt or notice showing filing or pending status of “Application for Asylum and Withholding” (I-589) and Employment Authorization Document (Card) (I-766) (annotated “C8”).

    • Cancellation of Removal or Suspension of Deportation with employment authorization.

      • Receipt or Notice showing filing Form EOIR-40, EOIR-42, or “Application for Suspension of Deportation or Special Rule Cancellation of Removal” (I-881) and Employment Authorization Document (Card) (I-766)

25. Amerasian immigrant

26. Pending application for Creation of Record of Lawful Admission for Permanent Residence, with Employment Authorization

Proof of Income

Note: Self-attestation of income in a written statement signed under a penalty of perjury is accepted on a case-by-case basis.

Attestation of Income, No Documentation Available (PDF)

Submit a copy of one of the following documents.

Earned Income: Employer Wages

1. Pay stub. It must include:

   • Full name of the person or other identifying information to link to the person (e.g. SSN). Social Security card is not necessary.

   • Income amount.

   • Pay period or frequency of pay with the date of payment.

2. Most recently filed Federal Income Tax Form 1040, with any appropriate Schedules. It must include:

   • Full name of the person or other identifying information to link to the person (e.g. SSN).

   • Income amount.

   • Tax year.

3. Wage/Income Tax Statement (such as a W2, 1099MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099SS, 1099INT, or 1099NEC, or other form displaying your income and taxes).​​​​​​

   • It must contain the person’s first and last name, income amount, year, and employer name (if applicable).

4. Employer statement. The employer statement must:

   • Be on company letterhead or state the name of the company.

   • Be signed by the employer.

   • Be no older than 45 days from the date received by Covered California.

   • Include the following information:

     • Name of employer or company.

     • Name of person writing the letter.

     • Employer or company address.

     • Employer or company telephone number.

     • Date of the letter.

     • The start date and, if applicable, the end date of the employee’s employment or pay.

     • The following two statements:

       • “I certify that [first and last name of person employed or receiving income] is/was an employee of [name of company]. [Employee name]’s gross income for this pay period is/was $__________ and frequency of pay is [weekly, every two weeks, twice a month, or monthly]. This letter does not guarantee employment or wages.”

       • “The information provided above is true and correct to the best of my knowledge.”

     • Signature of the person writing the letter.

     • Printed name and job title or position of the person signing the letter.

     • View a sample employer statement.

5. Foreign Income.

   • Pay stub, other documents.

   • Use dollar conversion based on date of document.

Earned Income: Self-Employment (includes farm income)

1. Self-employment Profit and Loss Statement or Ledger documentation (the most recent quarterly or year-to-date profit and loss statement, or a self-employment ledger). It must contain:

   • The person’s first and last name and company name.

   • Dates covered and the net income from profit/loss.

2. Federal Tax Form 1040 with any appropriate Schedules.

Unearned Income

1. Annuity statements.

2. Statements of pension distribution from any government or private source.

3. Prizes, settlements, and awards, including alimony received and court-ordered awards letters. For divorce or separation documents dated after Dec. 31, 2018, alimony received is not counted as taxable income.

4. Proof of taxable gifts and contributions.

5. Proof of taxable scholarships or grants — for room and board only, not tuition, course-related fees, books or equipment. 

6. Proof of strike pay and other benefits from unions.

7. Sales receipts or other proof of money received from the sale, exchange or replacement of things the person owns.

8. Interests and dividends income statement.

9. Royalty or residual income statement or 1099-MISC.

10. Letter, deposit, or other proof of deferred compensation payments.

11. Social Security Administration Statements (Social Security Benefits Letter).

    • Retirement, Survivors Disability Insurance (RSDI), Social Security Retirement, Social Security Disability Insurance (SSDI).

    • It must contain first and last name, benefit amount, and frequency of pay.

12. Unemployment Benefits Letter.

    • It must contain the person’s first and last name, source/agency, weekly benefits amount, and duration (start and end date, if applicable).

Proof of Non-Incarcerated Status

Submit a copy of one of the following documents.

1. Official release papers from the institution or Department of Corrections.

2. Parole papers.

3. Non-Incarceration Attestation Form.

Proof of Lack of Minimum Essential Coverage (MEC)

Submit a copy of one of the following documents.

1. Certificate of coverage or letter from the health plan issuer showing the end date of coverage.

2. Government-issued document showing date of termination of coverage or ineligibility to program.

3. Employer statement indicating no offer of affordable minimum value employer-sponsored coverage.

4. Self-attestation, where the individual is unable to provide any of the above documents.

To show lack of Medicare eligibility or enrollment:

1. Letter or statement from Medicare or the Social Security Administration stating that you or your family members are:

   • Not eligible for or enrolled in premium-free Medicare Part A; or

   • Eligible for (but not enrolled in) Part A coverage that requires premium payments. Important: A Social Security document that shows you don’t pay a premium for “Medical Insurance” refers to Part B. It’s not acceptable for verifying eligibility for Part A; or

   • No longer eligible for Social Security Disability Insurance (SSDI) benefits, and your coverage has ended or will end in the next 90 days.

2. If you are unable to obtain this letter, you may complete and submit an Attestation of Medicare Eligibility and Enrollment Status form.

Proof of American Indian and Alaska Native Status

Submit a copy of one of the following documents.

1. Tribal Enrollment/Membership Card.

2. Authentic document from a tribe declaring membership for an individual.

3. I-872 American Indian Card.

4. U.S. American Indian/Alaska Native tribal enrollment or shareholder documentation.

   • Enrollment or membership document from a federally-recognized tribe or the Bureau of Indian Affairs. It must be on tribal letterhead or an enrollment/membership card that contains the tribal seal and/or an official signature.

   • Document issued by an Alaska Native village/tribe, or an Alaska Native Corporation Settlement Act (ANCSA) regional or village corporation acknowledging shareholder status.

5. Certificate of Degree of Indian Blood (CDIB) issued by the Bureau of Indian Affairs or a tribe, if the CDIB includes tribal enrollment information.

6. Letter from the U.S. Department of Health and Human Services (HHS) granting a tribal exemption based on tribal membership or Alaska Native shareholder status.

Notification of Deceased Status

Please notify us if someone with a health plan through Covered California has died.

1. Courtesy Notification of Deceased (HBEX 411a)

2. Notification of Deceased by an Enrolled Member (HBEX 411b)

3. Notification of Deceased by Estate Rep. (HBEX 411c)

The following documents are accepted as proof of death:

• Copy of Death Certificate.

• Bureau of Vital Statistics records.

• Widow or survivor’s benefits on the deceased individual’s Social Security number (SSN).

• Veterans Administration or military service records.

• Hospital or medical records.

• Signed funeral director’s statement.

• Indian census records.

• Newspaper death notice (obituary).

• Insurance company records.

• Social Security records.

• Institutional records.

• Veterans Administration death payment correspondence.

• Insurance company death settlement correspondence.

• Minister or clergy statement.

• Proof of executor.

• Proof of estate.

• Probate court order (or Letter of Testamentary).

• Copy of a recorded Affidavit of Death of a Joint Tenant.

• Copy of a notarized Affidavit for Collection of Personal Property.

To confirm that someone with coverage through Covered California is not deceased, please submit a signed declaration or affidavit from the affected consumer or an authorized representative that the individual is not deceased. The declaration or affidavit must include:

1. Statement that the affected consumer is not deceased.

2. Statement that the information provided is true and correct to the best of the affected consumer’s knowledge.

3. The date and the signature of the affected consumer or their authorized representative.