2025 Marketplace Open Enrollment November 1-January 15 

HCA Required Documentation Samples

Listed below are samples of documentation you will need to fill out forms or send to us for proof of your Marketplace plan.

Oregon

Premium Bill Samples

Healthcare.gov Sample

Go to your healthcare.gov account and go to “My plans & programs.”

Providence Premium Bill Sample

The Providence premium bill does not show your plan name. Go to your healthcare.gov account and go to “My plans & programs.”

Washington

Marketplace Eligibility Notice Samples

For more information

Visit these pages to learn more about your benefits and how to use them if you are eligible:
Forms Webpage
Healthcare Cost Assistance Webpage
FAQs Webpage
MyCarewell503

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