Letter of Explanation Form

Fill out form below.

If you have received a notice from the Nevada Health Link requesting that you submit documents to confirm a life event, you will need to email or mail documents to Nevada Health Link. If you cannot provide the requested documents, you may submit this “letter of explanation.”

Fill out form below and the section that’s related to your life event

Disclaimer: The information requested below is to provide Nevada Health Link justification as to why you cannot submit the generally requested documents pertaining to your reported change. The information provided on this form will not be used to alter information within your application. You must report all changes through your application. If you accept any Advance Premium Tax Credits (APTC) and are deemed not eligible for the subsidies when you file your taxes you may be required to pay those subsidies back upon tax filing.

  • Loss of Coverage/ Prior Coverage (Must have Minimum Essential Coverage)

  • Move

  • Marriage

  • Denial of Medicaid or CHIP Coverage (only applicable if you applied during an enrollment period and were denied after the enrollment period)

  • Adoption, Foster Care Placement, Court Order or Gain of Tax Dependent

  • Income Verification/Loss of Income* (*Income verification may be applicable for any enrollment. If you are enrolling through a “Loss of Income” SEP, you will also need to provide evidence of prior coverage)

  • Additional Information

  • Max. file size: 100 MB.

Notice of Privacy Practices

Nevada Health Link is committed to maintaining the privacy and security of personally identifiable information. Nevada Health Link will use personally identifiable information only as permitted by Nevada Health Link’s policies and as required by law.

More information about Nevada Health Link’s privacy and security practices and your rights is available on Nevada Health Link’s website at Nevada Health Link’s Privacy Policy

If you need help understanding this form in another language, or if you are disabled and need help to use this form, please contact Nevada Health Link. There is no cost for assistance.

Note: Healthcare.gov will be processing requests for exemptions.  For more information please visit https://www.healthcare.gov/health-coverage-exemptions/

To complete via PDF: Letter of Explanation (PDF) Save this file to your computer, fill out the section that’s related to your life event, and email this form to: customerserviceNVHL@exchange.nv.gov. If you need more space, you may include an additional document or sheet.

Letter of Explanation (Spanish)


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