Form Ma 1099-Hc - Individual Mandate Massachusetts Health Care Coverage - 2015
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12015
Form MA 1099-HC
Massachusetts
Individual Mandate
Department of
Massachusetts Health Care Coverage
Revenue
1. Name of insurance company or administrator
2. FID number of insurance co. or administrator
3. Name of subscriber
4. Date of birth
5. Subscriber number
6. Street address
7. City/Town
8. State
9. Zip
Full-year minimum creditable coverage? If No, check months with minimum creditable coverage:
Corrected:
Yes
No
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
a. Name of dependent
Date of birth
Subscriber number
Full-year minimum creditable coverage? If No, check months with minimum creditable coverage:
Corrected:
Yes
No
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
b. Name of dependent
Date of birth
Subscriber number
Full-year minimum creditable coverage? If No, check months with minimum creditable coverage:
Corrected:
Yes
No
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
c. Name of dependent
Date of birth
Subscriber number
Full-year minimum creditable coverage? If No, check months with minimum creditable coverage:
Corrected:
Yes
No
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
d. Name of dependent
Date of birth
Subscriber number
Full-year minimum creditable coverage? If No, check months with minimum creditable coverage:
Corrected:
Yes
No
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
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