Schedule Hc-Cs - Health Care Information Continuation Sheet

Schedule Hc-Cs - Health Care Information Continuation Sheet - 2013

COMPLETE SCHEDULE HC-CS

TO REPORT ADDITIONAL

INSURANCE COMPANIES

SOCI L SECURITY NUMBER

FIRST N ME

M.I.

L ST N ME

Schedule H - S Health Care Information Continuation Sheet

2013

Complete Schedule HC-CS, Health Care Information Continuation Sheet, if you fill in the Full-Year MCC or Part-Year MCC oval(s) in line 3 of

Sched ule HC and had more than two private health insurance companies. Note: Your two most recent health insurance companies should be

reported on Schedule HC, line(s) 4f and/or 4g. Fill out the information below, using Form M 1099-HC, to report the information from your

additional in surance companies.

P RT . YOUR HE LTH INSUR NCE

3. N ME OF THIRD INSUR NCE COMP NY OR DMINISTR TOR IF NECESS RY (from box 1 of Form M 1099-HC)

FEDER L IDENTIFIC TION NUMBER OF INSUR NCE CO. (from box 2 of Form M 1099-HC)

SUBSCRIBER NUMBER (from Form M 1099-HC)

4. N ME OF FOURTH INSUR NCE COMP NY OR DMINISTR TOR IF NECESS RY (from box 1 of Form M 1099-HC)

FEDER L IDENTIFIC TION NUMBER OF INSUR NCE CO. (from box 2 of Form M 1099-HC)

SUBSCRIBER NUMBER (from Form M 1099-HC)

P RT B. SPOUSE’S HE LTH INSUR NCE

(you must complete even if covered under same insurance plan)

3. N ME OF THIRD INSUR NCE COMP NY OR DMINISTR TOR IF NECESS RY FOR SPOUSE (from box 1 of Form M 1099-HC)

FEDER L IDENTIFIC TION NUMBER OF INSUR NCE CO. (from box 2 of Form M 1099-HC)

SPOUSE’S SUBSCRIBER NUMBER (from Form M 1099-HC)

4. N ME OF FOURTH INSUR NCE COMP NY OR DMINISTR TOR IF NECESS RY FOR SPOUSE (from box 1 of Form M 1099-HC)

FEDER L IDENTIFIC TION NUMBER OF INSUR NCE CO. (from box 2 of Form M 1099-HC)

SPOUSE’S SUBSCRIBER NUMBER (from Form M 1099-HC)

Schedule Hc-Cs - Health Care Information Continuation Sheet - 2013