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Retrieve Your 1095-B Tax Form

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Please enter the required individual information that pertains to the 1095-B tax form that you would like to retrieve. Note: You can enter information for the head of household or any household members that received minimum coverage to retrieve a 1095-B form for the applicable tax year.

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Please enter your First Name.
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Please enter your Last Name.
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(Example: MM/DD/YYYY)
Please enter your Date of Birth. Please enter valid Date of Birth.

Please enter your County and Case Record number, CHIP Member ID, or UCI # that pertains to the information entered in the previous section.

If you need your UCI, contact your MCO provider or call the CHIP Call Center at 800-986-5437, option 5.


Please enter your SSN for this field or you may enter MCI Number, Medicaid ID, or EBT Card Number.

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Please select the tax year for the 1095-B form that you would like to retrieve and provide consent:


Please provide consent to receiving the 1095-B form electronically.


1095-B Tax Form

This Form 1095-B provides information needed to report on your income tax return that you, your spouse, and individuals you claim as dependents had qualifying health coverage (referred to as "minimum essential coverage") for some or all months during the year. Individuals who do not have minimum essential coverage and do not quality for an exemption may be liable for the individual shared responsibility payment.

Minimum essential coverage includes government-sponsored programs, eligible employer-sponsored plans, individual market plans, and miscellaneous coverage designated by the Department of Health and Human Services. For more information on minimum essential coverage, see Pub.974, Premium Tax Credit (PTC).

1095-B tax forms are displayed in PDF format. To view these form you will need Adobe Reader. PDF

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