Verification Forms

In some cases, Washington Healthplanfinder needs additional information about you in order for you to enroll in health coverage. Depending on your situation, use the verification forms below to give us the additional information.

Language assistance services, free of charge, are available to you. To speak with bilingual staff or an interpreter in your preferred language about the verification forms below, call our Customer Support Center at 1-855-923-4633 (TTY: 1-855-627-9604).

Employment Verification HBE 13-008

This form is used to verify an individual’s employment and income. The employee authorizes the employer to complete the verification form and submit the form on the employee’s behalf.

Declaration of Non-Incarceration HBE 13-009

Use this form to attest that you or someone in your household is not currently incarcerated in a city, county, state, or federal jail or prison. Incarceration status impacts eligibility for free or low-cost health insurance through Washington Healthplanfinder.

Declaration of Ineligibility for Other Minimum Essential Coverage HBE 13-010

Use this form to attest that someone in your household isn’t eligible for other Minimum Essential Coverage, despite your  Washington Healthplanfinder eligibility results indicating you have other coverage. Minimum Essential Coverage is health insurance an individual must have to meet the individual mandate. If you don’t have qualifying health coverage, you may have to pay a tax penalty.

Exception to Eligibility Verification for Income HBE 13-012

Use this form after you’ve tried and were unable to prove your household’s income to Washington Healthplanfinder. In this form, you’ll attest your household income and explain why you don’t have documents to submit to us.

Tribal Statement of Good Faith Effort – American Indian/Alaska Native HBE 15-008

Use this form to explain why you’re unable to provide verification of your membership in a federally-recognized tribe or Alaska Native Corporation.