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Exceptional Circumstances Special Enrollment Period

First Name:

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Last Name:

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Date of Birth:

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Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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Email:

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Phone:

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How should we contact you?

Reason for Exceptional Circumstance SEP Request

Tell us why you are asking for an Exceptional Circumstance Special Enrollment Period.

If you selected "other" as your reason for this request, please explain.

Date Exceptional Circumstance(s) Started

Select the date your exceptional circumstance started.

Date Exceptional Circumstance(s) Ended

For example: if you became medically incapacitated on 2/15/2020, that is the start date. If you were released from the hospital on 3/1/2020, that is the end date.

Access to Care Needs

Do you need medical care right now? For example, doctor's appointments or prescriptions?

If You Need Access to Care Right Now, Please Explain:

Tell us why you need access to care right now.

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Exceptional Circumstances Special Enrollment Period

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Example #2

Contact Information