PA STATE AGENCIES PA ONLINE SERVICES WHAT WE OFFER HELPFUL LINKS ABOUT CONTACT US LOGIN / REGISTER Retrieve Your 1095-B Tax Form 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. First Name * Last Name * Date of Birth * (Example: MM/DD/YYYY) Please enter your County and Case Record number, CHIP Member ID, or UCI # that pertains to the information entered in the previous section. County --Select-- 01 - Adams 02 - Allegheny 03 - Armstrong 04 - Beaver 05 - Bedford 06 - Berks 07 - Blair 08 - Bradford 09 - Bucks 10 - Butler 11 - Cambria 12 - Cameron 13 - Carbon 14 - Centre 15 - Chester 16 - Clarion 17 - Clearfield 18 - Clinton 19 - Columbia 20 - Crawford 21 - Cumberland 22 - Dauphin 23 - Delaware 24 - Elk 25 - Erie 26 - Fayette 27 - Forest 28 - Franklin 29 - Fulton 30 - Greene 31 - Huntingdon 32 - Indiana 33 - Jefferson 34 - Juniata 35 - Lackawanna 36 - Lancaster 37 - Lawrence 38 - Lebanon 39 - Lehigh 40 - Luzerne 41 - Lycoming 42 - Mckean 43 - Mercer 44 - Mifflin 45 - Monroe 46 - Montgomery 47 - Montour 48 - Northampton 49 - Northumberland 50 - Perry 51 - Philadelphia 52 - Pike 53 - Potter 54 - Schuylkill 55 - Snyder 56 - Somerset 57 - Sullivan 58 - Susquehanna 59 - Tioga 60 - Union 61 - Venango 62 - Warren 63 - Washington 64 - Wayne 65 - Westmoreland 66 - Wyoming 67 - York Case Record CHIP Member ID or UCI #. 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. SSN MCI # / Medicaid ID / EBT Card # (Click image for larger display) Please select the tax year for the 1095-B form that you would like to retrieve and provide consent: Tax Year* --Select-- 2020 2019 2018 2017 I consent to receiving the 1095-B Form electronically for this session only. 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. Already have Adobe and still having problems viewing your 1095-B tax form? Select the Help button for more information. Help Back to My COMPASS Home Page Submit Browser Compatibility Accessibility Privacy Policy HIPAA Notice of Privacy Practices Notice of Non-Discrimination