Health Insurance Questionnaire

2016 Health Insurance Information Worksheet

(Must be filled out prior to income tax appt.)
  • PLEASE BRING TO INITIAL TAX APPT:

    1) ANY form 1095-A, Form 1095-B or Form 1095-C you receive. 2) Proof of insurance coverage (insurance card, documentation from insurance company, etc.)
  • NOTE - MEDICARE COVERAGE:

    If you received medicare coverage for the entire year, you are NOT REQUIRED to complete this form.
  • Health Insurance Information

  • NOTE:

    In order to prepare your 2016 individual income tax return, the IRS requires that we have detailed information regarding your 2016 individual and family health insurance coverage. your assistance in completing the information detailed above is greatly appreciated.
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