Schedule Hc-Cs - Health Care Information Continuation Sheet - 2012
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1COMPLETE SCHEDULE HC-CS
TO REPORT ADDITIONAL
INSURANCE COMPANIES
SOCIAL SECURITY NUMBER
FIRST NAME
M.I.
LAST NAME
Schedule HC-CS Health Care Information Continuation Sheet
2012
Complete Schedule HC-CS, Health Care Information Continuation Sheet, if you fill in the Full-Year MCC or Part-Year MCC oval(s) in line 3 of
Schedule HC and had more than two private health insurance companies. Note: Your two most recent health insurance companies should be
reported on Schedule HC, line(s) 4f and/or 4g. Fill out the information below, using Form MA 1099-HC, to report the information from your
additional insurance companies.
PART A. YOUR HEALTH INSURANCE
3. NAME OF THIRD INSURANCE COMPANY OR ADMINISTRATOR IF NECESSARY (from box 1 of Form MA 1099-HC)
FEDERAL IDENTIFICATION NUMBER OF INSURANCE CO. (from box 2 of Form MA 1099-HC)
SUBSCRIBER NUMBER (from Form MA 1099-HC)
4. NAME OF FOURTH INSURANCE COMPANY OR ADMINISTRATOR IF NECESSARY (from box 1 of Form MA 1099-HC)
FEDERAL IDENTIFICATION NUMBER OF INSURANCE CO. (from box 2 of Form MA 1099-HC)
SUBSCRIBER NUMBER (from Form MA 1099-HC)
PART B. SPOUSE’S HEALTH INSURANCE
(you must complete even if covered under same insurance plan)
3. NAME OF THIRD INSURANCE COMPANY OR ADMINISTRATOR IF NECESSARY FOR SPOUSE (from box 1 of Form MA 1099-HC)
FEDERAL IDENTIFICATION NUMBER OF INSURANCE CO. (from box 2 of Form MA 1099-HC)
SPOUSE’S SUBSCRIBER NUMBER (from Form MA 1099-HC)
4. NAME OF FOURTH INSURANCE COMPANY OR ADMINISTRATOR IF NECESSARY FOR SPOUSE (from box 1 of Form MA 1099-HC)
FEDERAL IDENTIFICATION NUMBER OF INSURANCE CO. (from box 2 of Form MA 1099-HC)
SPOUSE’S SUBSCRIBER NUMBER (from Form MA 1099-HC)
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