Covered California Permission to Contact
Please complete this form to authorize contact regarding Covered California health coverage assistance.
YOUR PERMISSION
I authorize Cheryl Austin-Chaney Health Insurance Solutions (CACHIS) to contact me using the methods I selected above about Covered California health coverage, eligibility, enrollment assistance, and my related questions.
I understand that this permission is voluntary. It does not enroll me in a plan, authorize access to my Covered California account, or permit changes to my application. I may withdraw permission at any time by calling 951-410-8448 or replying STOP to a text message.
CACHIS will use the information on this form to respond to my inquiry and provide requested assistance. Standard message and data rates may apply to text messages. My services are provided at no cost to you.
Full Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
How may I contact you?
*
Phone calls
Text messages
Email
Best time to reach you
I have read and agree to the permission above.
*
I agree
Signature
*
Date signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: