Contact us - Apple Health (Medicaid) client
Please correct the following errors, or contact the Health Care Authority Customer Service Center at 1-800-562-3022:
All fields with a red asterisk is a required field and must be completed in order to submit.
Services Card Number:
Date of Birth:
(ex: 98444 or 98444-2294)
Subscriber Date of Birth:
Date Insurance Ended:
Name of Billing Provider:
Phone Number of Billing Provider:
Dates of Service:
If you require 1095-B to be reprinted for multiple tax years, please add
needed years into the Other Comments box.
Be sure your address includes all components of your mailing address, such as apartment and mail box numbers.
By selecting this box, you are declaring the information you have provided is either about yourself, or you are authorized to act on behalf of the person whose information you provided.
If submitting this form on behalf of someone other than yourself, please provide your name below:
All responses will be via email.