Fillable 1095-B Tax Form Request (Blue Cross and Blue Shield of Illinois)

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1095-B Tax Form Request (Blue Cross and Blue Shield of Illinois)

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244523.0122
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
You can still get your BCBSIL Form 1095-B
by request.
Your request must include:
Your N
ame
Your
Member ID Number
Your Group Number
To get your Form 1095-B, please mail this information to:
Blue Cross and Blue Shield of Illinois
c/o 1095-B Form Request
PO Box 660044
Dallas, TX 75266-0044
Your Form 1095-B will be mailed to your address on le within 30 days.
If you have any questions, please call the number on the back of your BCBSIL member ID card.
1
3
2
As a Blue Cross and Blue Shield of Illinois (BCBSIL) member, you’ll no
longer need the information on the Form 1095-B to le your federal
income taxes.
Name
Member ID Number
Group Number
Tax Year
1
3
2
1095-B Tax Form Request
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1095-B Tax Form Request (Blue Cross and Blue Shield of Illinois)

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Completed 19 March 2022

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