Health Coverage Information Request Form

Under the federal Affordable Care Act, almost everyone is required to have health coverage.

Since 2016:

• Kaiser Permanente has been required to report to the Internal Revenue Service (IRS) your enrollment in certain Kaiser Permanente health plans.* For this we need your Social Security number (SSN) or other Tax Identification Number (TIN) — and those of your family members covered under your plan.
• When filing your federal income tax return each year, you're required to provide proof of health coverage. For that purpose, we send a health coverage statement (Form 1095-B) each year.
• We’ll keep sending your form to you once a year for as long as you or your family are Kaiser Permanente members as required by law.

In the past, Kaiser Permanente wasn't required to collect your SSN/TIN. Now we must collect such information for reporting to the IRS. If we don't currently have your SSN/TIN (or your complete SSN/TIN) on file, we'll mail you a Health Coverage Information Request Form so you can provide it.

What is a Tax Identification Number?

Your Tax Identification Number is most likely your Social Security number. If it's not, it can be an Adoption Taxpayer Identification or Individual Taxpayer Identification Number.

What is the difference between a Social Security number and Tax Identification Number?

The Internal Revenue Service (IRS) uses Tax Identification Numbers (TINs) to identify taxpayers for reporting and other purposes. For most people, their Social Security number acts as their TIN. For others, it can be an Adoption Taxpayer Identification or an Individual Taxpayer Identification Number.

What happens if Kaiser Permanente doesn’t have my Social Security or other Tax Identification Number?

If we don’t have a Social Security or other Tax Identification Number for you or a member on your coverage plan on file, or if it's not complete, we'll mail you a Health Coverage Information Request Form to ask for it. If we already have it, we won’t contact you.

I (or some of my dependents) don’t have a Social Security or other Tax Identification Number. Can I send a visa number instead?

No. We don’t need your visa number. If you or your dependents don’t have SSNs/TINs, please return the form and let us know that you don’t have SSNs/TINs. However, if you write on the form that you or someone in your family doesn’t have a SSN/TIN, we will not contact you again (as required by law) to ask for this information.

I (or some of my dependents) don’t have a Social Security number. Can I send another Tax Identification Number?

Yes, just write your other Tax Identification Number on the form and return it in the prepaid envelope we gave you. You can also fax the form back to us at 855-355-5334.

I (or some of my dependents) don’t have a Social Security or other Tax Identification Number. What should I do?

That’s OK. If you don’t have a Social Security number (SSN) or other Tax Identification Number (TIN), please return the form and let us know that. We’ll use your names and dates of birth to create your Health Coverage statements (Form 1095-B).

I think I’ve given my Social Security or other Tax Identification Number to Kaiser Permanente before. Why are you contacting me again?

We’re contacting you because we don’t have a complete Social Security (SSN) or other complete Tax Identification Number (TIN) on file for you or your family members. If you have SSNs/TINs, please provide them for everyone under your coverage plan (or let us know if some of your family members don’t have SSNs/TINs). Then return the form in the prepaid envelope we gave you, or fax it back to us at 855-355-5334.

I lost my request form. Can I get a new one?

Yes. Call us at the number in your area to ask for a new form.

I lost the self-addressed stamped envelope that came with the request form. What’s the address to mail back my form?

Kaiser Permanente Health Plan, Inc.
California Service Center - MEC
P.O. Box 232400
San Diego, CA 92193-9919

You can also fax the form back to us at 855-355-5334 if you prefer.

Can I fax my form to Kaiser Permanente?

Yes, you can fax the form back to us at 855-355-5334.

Can I give you my Social Security or Tax Identification Number over the phone, through the website, or mobile app?

No. We need your signature on file to verify that your and your family members’ Social Security numbers (SSNs) or other Tax Identification Numbers (TINs) are correct. The only way for you to verify that your SSN/TIN is correct is to complete and sign the request form that we send you in the U.S. mail and return it in the prepaid envelope provided or fax the form back to us at 855-355-5334.

Kaiser Permanente doesn't call members asking them to provide personal information. The only Social Security number request that Kaiser Permanente is sending this year is by U.S. mail. You should never provide your Social Security number or any other personal information to an unsolicited caller.

Please note: If we don’t have a Social Security number for you on file, or if it's not complete, we'll mail a Health Coverage Information Request Form to you.

I want to return the signed form, but it’s past the "requested by" date. Can I still send it in?

Yes, you can still return it in the prepaid envelope we gave you, or fax the form back to us at 855-355-5334. Please do so as soon as possible, so we can update our records and create your Health Coverage statement (Form 1095-B).

The form I received has some incorrect information (such as name or address). What should I do?

Call us at the number listed below for your region or your area to update your information.

How will Kaiser Permanente use my Social Security or other Tax Identification Number for reporting?

We will use your Social Security or other Tax Identification Number (SNN/TIN) to:

• Report to the IRS that you have health coverage with Kaiser Permanente.
• Send you a Health Coverage Statement (Form 1095-B) each year for as long as you or your family are Kaiser Permanente members. You'll need these forms for filing your federal income tax return.

We may also use your SSN/TIN for any other purpose required or permitted by applicable law. This may include reporting other necessary information about your coverage to the federal government for purposes such as Medicare secondary coverage (if you’re age 44 or older and enrolled in fully insured group coverage).

If I don’t give you my Social Security number or other Tax Identification Number, will I lose my health coverage?

No. If you don’t send back the form, your health coverage won’t be affected. However, the IRS may give you a penalty for failing to provide tax-reporting information.

What happens if I don’t give Kaiser Permanente the Social Security or other Tax Identification number(s)?

We are required to request your SSN/TIN up to three times — once at enrollment then two additional times if you do not provide it to us. Also, you may have to pay an IRS penalty for failing to provide tax-reporting information.

I don’t want to provide my Social Security or other Tax Identification Number. What will happen if I don’t?

We are required to request your SSN/TIN up to three times — once at enrollment then two additional times if you do not provide it to us. Also, you may have to pay an IRS penalty for failing to provide tax-reporting information.

I just mailed back my Social Security or other Tax Identification Number request form. Have you received it?

We should receive your form within 7 to 10 business days (Monday through Friday, not including weekends or major holidays). You will see this change on the 1095-B form mailed to you for the coming year.

When will I receive the Health Coverage statement (Form 1095-B) from Kaiser Permanente?

We'll mail it to you by the mandated IRS deadline, in time to prepare your taxes.

Where can I learn more about the Affordable Care Act’s proof of coverage requirements?

You may find the following websites helpful:

• Questions and answers about reporting Social Security numbers to your health insurance company from the Internal Revenue Service
• Affordable Care Act tax provisions from the Internal Revenue Service
• How health coverage affects your federal income tax return from Healthcare.gov

Where do I call if I have questions?

Kaiser Permanente Customer Service is available 24 hours a day, 7 days a week, except on major holidays.

*Kaiser Permanente is only required to report enrollment in a Kaiser Permanente health plan for these commercial, fully insured plans: Kaiser Permanente Individual and Family plans purchased directly through Kaiser Permanente (KPIF Off-Marketplace), Small Group, SHOP (Small Business Health Options Program), FEHBP (Federal Employees Health Benefits Program), and Large Group. If you are a member of a self-funded plan, your employer is responsible for reporting directly to the IRS.

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