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/stakeholders/plan-management/PDFs/2017-18-Plan-Management-Advisory-Nomination-Form.pdf&sa=U&ved=2ahUKEwjbqrqUrKPyAhVDposKHdVJBKM4FBAWMAR6BAgEEAE&usg=AOvVaw2xYBicj2ck1ozapcnZLsrT