CoveredCA Delegation

Use the form below to delegate your case to a CalHealth certified CoveredCA agent. The delegation can be ended at any time by calling 1-800-300-1506.

What help do you need with CoveredCA?(Required)

Your Information

Please enter the required information below.

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth(Required)

Social Security Number(Required)

What is your address?(Required)

Street Address Address Line 2 City State ZIP Code

Upload an image of an approved government issued picture ID

Acceptable picture IDs are driver’s licenses, passports, or immigration cards. If no upload is provided, a CalHealth certified CoveredCA agent will be in contact.

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Any specifics regarding your health insurance needs?

Please have your documents gathered and ready. A CalHealth representative will be in contact to help you upload your documents.

The easiest way to keep your kids off of Medi-Cal is to overestimate your income and file an affidavit expressing your desired estimate income to be just beyond the Medi-Cal eligibility range. We would be happy to assist you in this process and it is best accomplished with the advice of an experienced CoveredCA agent. It is not fraudulent to overestimate a “guess” as to what your annual income will be. Finish submitting this form and a CalHealth representative will be in contact.

What is your new address?(Required)

Street Address Address Line 2 City State ZIP Code

List the family members you wish to add

First Name

Last Name

Date of Birth

SSN

List the family members you wish to remove

First Name

Last Name

Date of Birth

SSN

Finish submitting this form and a CalHealth representative will be in contact to help you with your Medicare enrollment needs.

What is your martial status?(Required)

What is your new estimated yearly income?(Required)

What type of help do you need with CoveredCA?(Required)

Consent to Delegation

Consumer consent to delegate case to CalHealth certified CoveredCA agent. Please read the below statements to the Consumer for delegation consent. Please select the checkboxes below to provide consent for each statement on behalf of the Consumer.