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Form 1095 B for Santa Clara California: What You Should Know

To order a form, you must log in to your Member Account and click on the “Order” link above to access the Member Application. CMS Form 3811 — Claim for Refund for the 2025 Calendar Year All Members are required to submit their 2025 annual claim for Refund for the 2025 calendar year. To complete this form, please click on the link below. This is not a form you submit by yourself. Once your claim is received and processed, it will be sent to the Claimant for review. CMS Form 8379 — Notice of Change in Plans All Members are required to submit to CMS the Notice of Change in Plans. To complete this form, please click on the link below. This form may only be submitted by the individual member who was enrolled in the plan change. Once the claim is received and processed, it will be sent to the Member for review. 2 Medical Plan Change Request Forms For informational purposes only. Each Individual Member who was enrolled for, or who is now enrolled, in, a California Medicare program for the 2018‑2019 Medical Plan Change is required to file this form with the Secretary of Health and Human Services by June 9, 2018. If you miss the July 1, 2018, due date, you will be required to submit a new form and be subject to penalties under the Affordable Care Act (ACA). To file a Medical Plan Change form via the Internet, please click here or click on the links below: For an Individual Member of Health Plan Change Complete the form below, enclose the completed form with the 200 application fee, and mail or file within 120 days: Medical Plan Change Form - 2025 – 2019 Individual Member (2018 – 2025 Medical Plan Change)​ (2018 – 2019) Copy of your California ID Card (if applicable) Photo ID or SSN of the Plan Holder​ (if applicable) California State Driver's License, State Issued ID, or Voter's Card(If applicable) Copy of Employee ID (Exceptions: If you are exempt from California state income tax, then you must provide proof of income) Fee for filing claim: 200.00 250.00​ 500.00​ 1000.00​ 2000.

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