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Printable Form 1095-C Allegheny Pennsylvania: What You Should Know

Each time you get a Form 1095-C, you may be asked to complete and submit a one-page application to the Department of Labor's  Office of the Unemployment Insurance Trust Fund. Form 1095-C, Patient and Member Form If you need a list of health insurance provider by address, you can download Form 1095-C Guide to Provider Information. Form 1095-C, Patient and Member Form, Optional Form When you submit Form 1095-C, you can print two optional forms. One is  Form 1095-C, Patient and Member Form–If you are applying for health insurance by submitting a new enrollment form online. Form 1095-C, Patient and Member Form, Required Form Use this form if you are applying for health insurance by using the Exchange. Additional Information If you would like to request certain additional information about your health insurance, use a paper form. You can download the paper form and use it in place of the Electronic Form.  You can also use Form 8889-T, Application by Third Party with Insurance Coverage or Medicare Parts A and B, to submit an application for a group health insurance coverage or for Medicare. Furthermore, you may also fill out the form and submit to the Medicare or Medicaid administrative agencies and agencies of each State. For more information about health insurance plans, see Section 7. “Health Insurance.” For information about eligibility for benefits under the Health Care Independence and Transitional Assistance Act, see § 1344(f).

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