This government document is issued by California Health Benefit Exchange for use in California
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https://www.google.com/url?client=internal-element-cse&cx=009854164935538441977:yzlo2be1knm&q=https://hbex.coveredca.com/community-outreach-network/forms/interest-form.pdf&sa=U&ved=2ahUKEwjw8raCpaPyAhVppYsKHfQ9C9AQFjAGegQICRAC&usg=AOvVaw26O11shcmATUqyxB9rYuil