Section

DHS-8071-ENG 1-21 (1.0.2)

Policy — Health Care Administration

Form 1095-B Request

Fields with an asterisk (*) are required; you will not be able to submit your request unless completed. If you are unable to provide the required information, call 651-297-3862 or toll free 800-657-3672 and a representative will assist you with your request.

FIRST NAME

LAST NAME

PHONE NUMBER

EMAIL ADDRESS

DATE OF BIRTH

STREET ADDRESS

CITY

STATE

ZIP CODE

CASE NUMBER

NAME(S) OF FAMILY MEMBER(S) REQUESTING A FORM 1095-B

FORM 1095-B TAX YEAR(S) REQUESTED

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