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.
Please enter the Case or you may enter CHIP Member ID or UFI Number that pertains to the information entered in the previous section.
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.