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This form is for individuals who were a resident of Massachusetts in the reporting tax year that you are requesting.  "Popups" must be enabled in order to use this tool.

The following fields are required and should be entered exactly as it appears on your Harvard Pilgrim ID card:
  • Subscriber's name
  • Subscriber's date of birth
  • Subscriber's Identification number (begins with HP)

If you wish for your address to appear on the form, please complete the address fields below, otherwise it will appear blank on the form.

If you wish to include any or all of the dependents that were on your policy during the reporting period, you must enter the dependent information requested below. If you enter a dependent that was not covered during the reporting period, they will not be included on the form.

If the subscriber was not a Massachusetts resident during the requested reporting period, please contact Harvard Pilgrim Member Services at 1-888-333-4742 for assistance in generating a form.



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Dep Info
Please enter the name(s) and date(s) of birth for dependents you wish to include on the 1099-HC form. Dependents are any members covered on your
policy. Note that the dependent name(s) on the 1099-HC form will appear as entered below.

Dependent Information:


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Request 1099-HC