Forms & publications

Document type

Topic

Customer type

Year

Plan

Sort by

Premium Surcharge Attestation Change form (SEBB) 2026

The 2026 SEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.

20-0041
Form

Free or low-cost health care
- I need medical, dental, or vision care
  - Find Apple Health benefits & services
  - Other Apple Health programs
  - Am I eligible?
  - Learn about my coverage
  - Use my coverage
  - Manage my coverage
- I need behavioral health support
  - Mental health
  - Substance use
  - Prenatal, children & young adults
  - American Indians & Alaska Natives
    - Behavioral health services for American Indians & Alaska Natives (AI/AN)
  - Recovery support services
  - Prevention
    - Substance use disorder prevention & mental health promotion
- I help others apply for & access Apple Health
  - Apple Health Eligibility Manual
  - Additional tools
  - Stakeholder training & education
- Quick links
- Contact Apple Health (Medicaid)
- News
Employee & retiree benefits
- Public employees
  - Find benefits
  - Explore costs
  - Determine eligibility
    - Am I eligible?
    - Are my dependents eligible?
  - Learn how to enroll
  - Manage benefits
  - Get help
- School employees
  - Find benefits
  - Explore costs
  - Determine eligibility
    - Am I eligible?
    - Are my dependents eligible?
  - Learn how to enroll
  - Manage benefits
  - Get help
- Retirees
  - Get started
  - Benefits
  - Costs
  - Manage coverage
  - Tools & resources
  - Help
- PEBB Continuation Coverage
  - Find benefits
  - Explore costs
  - Determine eligibility
    - Am I eligible?
    - Are my dependents eligible?
  - Learn how to enroll
    - For newly eligible members
    - Verify & enroll my dependents
  - Manage benefits
  - Get help
- SEBB Continuation Coverage
  - Find benefits
  - Explore costs
  - Determine eligibility
    - Am I eligible?
    - Are my dependents eligible?
  - Learn how to enroll
    - For newly eligible members
    - Verify & enroll my dependents
  - Manage benefits
  - Get help
- Quick links
- Contact us
- PEBB news
- SEBB news
Billers, providers & partners
- Prior authorization, claims & billing
  - Getting started
  - Submit prior authorization (PA)
    - Step-by-step guide for prior authorization (PA)
    - Pharmacy prior authorization
  - Submit claims
    - Provider billing guides & fee schedules
    - Hospital rates & reimbursement
- Program information for providers
- Become an Apple Health provider
  - Learn how to enroll
  - What's next
    - Track my application
    - Find next steps for new Medicaid providers
  - For existing medicaid providers
    - Update my provider information
    - Revalidation
- Learn ProviderOne
  - Getting started
    - Setup ProviderOne access for your organization
    - ProviderOne access: FAQs
  - Training materials
- Quick links
- Contact us
- News
About HCA
- Programs & initiatives
- Who we are
  - About us
  - Boards, committees & collaborations
  - Health innovation
- Data & reports
- Other administrative activities
  - Medicaid-related
  - Government transparency
    - Public disclosure request
  - Community services
    - Disaster outreach
    - Voter registration
- News
  - Find out what's new
  - Follow HCA on social media
  - For the press
    - Visit our press room
- Quick links
- Contact HCA
Contact
Youth and young adult substance use treatment
Login