Pennsylvania Health Insurance Coverage Information Request

Health Insurance Coverage Information Request
Health Insurance Coverage Information Request (REV-1882)
2110010051
(EX) MOD 07-21 (FI)

REV-1882

HEALTH INSURANCE COVERAGE
INFORMATION REQUEST

Name shown first on the PA-40 (if filing jointly)

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Social Security Number

PURPOSE: The purpose of the REV-1882, Health Insurance Coverage Information Request, is to connect uninsured Pennsylvanians with
information regarding their eligibility to enroll in health insurance coverage through the Pennsylvania Health Insurance Exchange Authority,
also known as Pennie™. Pennie is Pennsylvania’s health insurance marketplace. The Pennsylvania Department of Revenue and Pennie
have teamed up to gather information from residents who do not have health insurance coverage, making it easier to apply and enroll in
comprehensive health insurance through Pennie. 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 so that
Pennie can evaluate your eligibility for no-cost or low-cost health care coverage.
Email Address

Telephone 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 Pennie to communicate with you via telephone or email . . . . 4.
5. Please provide your adjusted gross income from Line 11 of your federal tax return . . . . . . . . . . 5.

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6. Please provide the number of household members included on your federal tax return . . . . . . . 6.
7. 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)

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Instructions for REV-1882

REV-1882 IN (EX) 07-21

GENERAL INFORMATION
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.
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, please visit
www.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 address and
telephone number where indicated.

www.revenue.pa.gov
RETURN TO PAGE 1

Health Insurance Coverage Information Request
LINE INSTRUCTIONS
LINE 1
Fill in the oval if the primary taxpayer does not have health
insurance coverage.

LINE 2
Fill in the oval if the primary taxpayer’s spouse (if married
filing jointly) does not have health insurance coverage.

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 Pennie to communicate
with you via telephone or email.

LINE 5
Provide your adjusted gross income from Line 11 of your
federal tax return.

LINE 6
Provide the number of household members included on your
federal tax return.

LINE 7
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.

REV-1882

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