You can ask for a fast (expedited) appeal if you think waiting for a standard decision may seriously jeopardize your life, health, or ability to attain, maintain, or regain maximum function.
Signature: have the tax filer on the Marketplace application sign the form (Step 7).
Filing delay: if you're filing this appeal more than 90 days after the date on the Marketplace Eligibility Notice, also explain the delay.
Documents: submit copies, not originals, since your documents won't be returned.
Authorized representative: if you appoint one, they'll be the main contact during your appeal.
| Question | Answer |
|---|---|
| Form Name | Form CMS-12153 |
| Form Length | 8 pages |
| Fillable? | Yes |
| Fillable fields | 62 |
| Avg. time to fill out | 11 min |
| Filing Deadline | 90 days from Marketplace Eligibility Notice |
| Issuing Authority | Health Insurance Marketplace (healthcare.gov) |
| Edition | Rev 02/2025 |
| Where to send | By mail: Health Insurance Marketplace, Attn: Appeals, 465 Industrial Blvd., London KY 40750-0061, or by secure fax: 1-877-369-0130 |
| Filing deadline | Within 90 days of the date on the Marketplace Eligibility Notice you're appealing |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | CMS-12153, Form CMS-12153, Marketplace Appeal Request Form A, Marketplace Appeal Request Form, Marketplace Eligibility Appeal Request, appeal request form |
| Official source | Marketplace Appeal Request Form A, CMS-12153 (02/2025), Health Insurance Marketplace |
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