Pennsylvania Health Insurance Coverage Information Request

Health Insurance Coverage Information Request
2024 Health Insurance Coverage Information Request (REV-1882)
2410010058
(EX) MOD 03-24 (FI)

REV-1882

HEALTH INSURANCE COVERAGE 
INFORMATION REQUEST

2024

IMPORTANT: This Schedule is for tax year 2024 only. If you are filing this form for a different tax year, please refer to the department's website.
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Name (if filing jointly, use name shown first on the PA-40)

Social Security Number

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PURPOSE: The purpose of the REV-1882 Health Insurance Coverage Information Request is to give uninsured Pennsylvanians information
about enrolling in a health insurance plan through Pennie®, Pennsylvania’s official health insurance marketplace (pennie.com). The
Pennsylvania Department of Revenue and Pennie developed this easy way for residents who do not have health coverage to apply and
enroll in high-quality, comprehensive health insurance and receive financial savings to lower healthcare costs. If you, your spouse (if married,
filing jointly), or any dependents in your household do not have health insurance, make sure to answer the questions below. By answering
the questions below, you are giving permission for the Pennsylvania Department of Revenue to share information from your state tax return
(such as your household size and income) with Pennie, and for Pennie to send you postal mail with personalized information regarding the
amount of financial savings for which you are eligible and next steps in enrolling in a high-quality health plan.
Email Address

Phone Number

1. Select oval if you do not have health insurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.
2. Select oval if your spouse (if married, filing jointly) does not have health
insurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.
3. Select oval if any dependents included on your federal tax return do not have health
insurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.
4. Select oval if you consent to allow the Pennsylvania Department of Revenue to share
information from your PA-40 tax return and the REV-1882 with Pennie to determine
eligibility for savings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.
5. Select oval if you consent to allow Pennie to communicate with you via phone or email . . . . . . . 5.
6. Please provide your adjusted gross income from Line 11 of your federal tax return . . . . . . . . . . 6.

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7. Please provide the number of household members included on your federal tax return . . . . . . . 7.
8. Please provide the date of birth for yourself, your spouse (if married, filing jointly), and all tax
dependents under age 26 within your household who do not have health insurance coverage.
Taxpayer Date of Birth (MM/DD/YYYY)

Spouse Date of Birth (if married, filing jointly)
(MM/DD/YYYY)

Dependent(s) Date(s) of Birth (MM/DD/YYYY)

2410010058

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2024
Instructions for REV-1882

Health Insurance Coverage Information Request

REV-1882 IN (EX) 03-24

GENERAL INFORMATION

LINE 2

The Pennsylvania Health Insurance Exchange Authority,
also known as Pennie®, is Pennsylvania’s state-based
health insurance marketplace providing Pennsylvanians
with access to affordable health insurance. Pennie has
partnered with the Pennsylvania Department of Revenue to
establish a program whereby Pennsylvanians can provide
eligibility information to Pennie while filing their Pennsylvania
Income Tax return.

Fill in the oval if the primary taxpayer’s spouse (if married
filing jointly) does not have health insurance coverage.

PURPOSE OF FORM
The purpose of the REV-1882, Health Insurance Coverage
Information Request, is to provide uninsured Pennsylvanians
with a way to submit information to Pennie. Pennie will use
this information to assist you in determining your eligibility
for enrollment in health insurance with financial assistance.
For additional information regarding Pennie, visit
pennie.com.
If you are uninsured and want to understand your eligibility
for health insurance through Pennie, you can complete this
form. By completing this form and attaching it to your signed
Pennsylvania Personal Income Tax Return, you authorize
the Department of Revenue to supply tax information from
your return (including your name, address, and Social
Security number) and the information provided on this form
to Pennie.
NOTE: Executing this form is completely voluntary.
You are not required to fill out this form to file your
Pennsylvania Personal Income Tax Return.

FORM INSTRUCTIONS
Provide the primary name, primary SSN, email, and phone
number where indicated.

LINE INSTRUCTIONS

LINE 3
Fill in the oval if any dependents included on your federal
tax return do not have health insurance coverage.

LINE 4
Fill in the oval if you consent to allow the PA Department of
Revenue to share information from your PA-40 tax return
and the REV-1882 with Pennie.

LINE 5
Fill in the oval if you consent to allow Pennie to communicate
with you via phone or email.

LINE 6
Provide your adjusted gross income from Line 11 of your
federal tax return.

LINE 7
Provide the number of household members included on your
federal tax return.

LINE 8
Provide the name and date of birth (MMDDYYYY) for the
primary taxpayer and the primary taxpayer’s spouse (if
married filing jointly).
Provide the date of birth (MMDDYYYY) of the dependent(s)
(from Line 3) within your household who are under age 26
and who do not have health insurance coverage.

LINE 1
Fill in the oval if the primary taxpayer does not have health
insurance coverage.

revenue.pa.gov
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REV-1882

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