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		This form is for individuals who were a resident of Massachusetts in the reporting tax year being requested.  "Popups" must be enabled in order to use this tool. As Medicare coverage automatically meets the requirements for qualifying health insurance, Harvard Pilgrim subscribers on Medicare Supplement and Medicare Enhance plans will not receive a 1099-HC form. The following fields are required: Subscriber's first name and last name Subscriber's date of birth Subscriber's identification number (first 9 characters including letters and numbers), e.g. HP1234567 If you are a dependent who resides in MA and the subscriber (policy holder) was not a MA resident, then please enter your member information in all of the required fields, including the full 11 character member ID number, e.g. HP123456702 If you wish for your address to appear on the form, please complete the address fields below; otherwise, it will not be included on the form. If you wish to include any or all of the dependents who were on your policy during the reporting period, you must enter the dependent information requested below. If you enter a dependent who was not covered during the reporting period, they will not be included on the form. Please contact Harvard Pilgrim Member Services at (888)-333-4742 if you need additional assistance. Subscriber Information (* indicates a required field): First Name Last Name Date of Birth (MM/DD/YYYY) Subscriber ID Reporting Year 2023 2022 2021 2020 Street Street 2 City/Town State Zip Dep Info Please enter the name(s) and date(s) of birth for dependents you wish to include on the 1099-HC form. Dependents are any members covered on your policy. Note that the dependent name(s) on the 1099-HC form will appear as entered below. Dependent Information: First Name Last Name Date of Birth (MM/DD/YYYY) First Name Last Name Date of Birth (MM/DD/YYYY) First Name Last Name Date of Birth (MM/DD/YYYY) First Name Last Name Date of Birth (MM/DD/YYYY) First Name Last Name Date of Birth (MM/DD/YYYY) First Name Last Name Date of Birth (MM/DD/YYYY) First Name Last Name Date of Birth (MM/DD/YYYY) First Name Last Name Date of Birth (MM/DD/YYYY) First Name Last Name Date of Birth (MM/DD/YYYY) First Name Last Name Date of Birth (MM/DD/YYYY) Request 1099-HC