Form 1095-B Health Coverage

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TREASURY/IRS AND OMB USE ONLY DRAFT
Form

1095-B

Department of the Treasury
Internal Revenue Service

Part I

560118
VOID

Health Coverage
Do not attach to your tax return. Keep for your records.
Go to www.irs.gov/Form1095B for instructions and the latest information.

OMB No. 1545-2252

2025

CORRECTED

Responsible Individual

1 Name of responsible individual–First name, middle name, last name
4 Street address (including apartment no.)

5 City or town

2 Social security number (SSN) or other TIN

3 Date of birth (if SSN or other TIN is not available)

6 State or province

7 Country and ZIP or foreign postal code

9 Reserved
8 Enter letter identifying Origin of the Health Coverage (see instructions for codes):

Part II

.

.

.

.

.

Information About Certain Employer-Sponsored Coverage (see instructions)

10 Employer name

Part III

13 City or town

15 Country and ZIP or foreign postal code

17 Employer identification number (EIN)

18 Contact telephone number

21 State or province

22 Country and ZIP or foreign postal code

Issuer or Other Coverage Provider (see instructions)

16 Name
19 Street address (including room or suite no.)

Part IV

14 State or province

20 City or town

Covered Individuals (Enter the information for each covered individual.)
(a) Name of covered individual(s)
First name, middle initial, last name

(b) SSN or other TIN

(c) DOB (if SSN or other (d) Covered
TIN is not available) all 12 months

(e) Months of coverage

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

23

24

25

26

27

28
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 60704B

Form 1095-B (2025) Created 5/28/25

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

12 Street address (including room or suite no.)

11 Employer identification number (EIN)

TREASURY/IRS AND OMB USE ONLY DRAFT

Page 2

Form 1095-B (2025)

Instructions for Recipient
This Form 1095-B provides information about the individuals in your tax
family (yourself, spouse, and dependents) who had certain health coverage
(referred to as “minimum essential coverage”) for some or all months during
the year. Minimum essential coverage includes government-sponsored
programs, eligible employer-sponsored plans, individual market plans,
and other coverage the Department of Health and Human Services
designates as minimum essential coverage.

Providers of minimum essential coverage are required to furnish
only one Form 1095-B for all individuals whose coverage is
reported on that form. As the recipient of this Form 1095-B, you
should provide a copy to other individuals covered under the policy if they
request it for their records.

TIP

Additional information. For additional information about the tax provisions
of the Affordable Care Act (ACA) and the premium tax credit, see
www.irs.gov/ACA or call the IRS Healthcare Hotline for ACA questions
(800-919-0452).
Part I. Responsible Individual, lines 1–9. Part I reports information about
you and the coverage.
Lines 2 and 3. Line 2 reports your social security number (SSN) or other
taxpayer identification number (TIN), if applicable. For your protection, this
form may show only the last four digits. However, the coverage provider is
required to report your complete SSN or other TIN, if applicable, to the IRS.
Your date of birth will be entered on line 3 only if line 2 is blank.
Line 8. This is the code for the type of coverage in which you or other
covered individuals were enrolled. Only one letter will be entered on this line.
A. Small Business Health Options Program (SHOP)
B. Employer-sponsored coverage
C. Government-sponsored program
D. Individual market insurance
E . Multiemployer plan
F . Other designated minimum essential coverage
G . Individual coverage health reimbursement arrangement (HRA)

If you or another family member received health insurance
coverage through a Health Insurance Marketplace (also known as
an Exchange), that coverage will generally be reported on a
Form 1095-A rather than a Form 1095-B. If you or another family member
received employer-sponsored coverage, that coverage may be reported on a
Form 1095-C (Part III) rather than a Form 1095-B. For more information, see
www.irs.gov/Affordable-Care-Act/Questions-and-Answers-About-HealthCare-Information-Forms-for-Individuals.

TIP

Line 9. Reserved.
Part II. Information About Certain Employer-Sponsored Coverage, lines
10–15. If you had employer-sponsored health coverage, this part may
provide information about the employer sponsoring the coverage. This part
may show only the last four digits of the employer’s EIN. This part may also
be left blank, even if you had employer-sponsored health coverage. If this
part is blank, you do not need to fill in the information or return it to your
employer or other coverage provider.
Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports
information about the coverage provider (insurance company, employer
providing self-insured coverage, government agency sponsoring coverage
under a government program such as Medicaid or Medicare, or other
coverage sponsor). Line 18 reports a telephone number for the coverage
provider that you can call if you have questions about the information
reported on the form.
Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN
or other TIN, and coverage information for each covered individual. A date of
birth will be entered in column (c) only if the SSN or other TIN is not entered
in column (b). Column (d) will be checked if the individual was covered for at
least 1 day in every month of the year. For individuals who were covered for
some but not all months, information will be entered in column (e) indicating
the months for which these individuals were covered. If there are more than
six covered individuals, see Part IV, Continuation Sheet(s), for information
about the additional covered individuals.

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

If individuals in your tax family are eligible for certain types of minimum
essential coverage, you may not be eligible for the premium tax credit. For
more information on the premium tax credit, see Pub. 974, Premium Tax
Credit (PTC).

560220

TREASURY/IRS AND OMB USE ONLY DRAFT

560318
Page 3

Form 1095-B (2025)
Social security number (SSN) or other TIN

Name of responsible individual–First name, middle name, last name

Part IV

Date of birth (if SSN or other TIN is not available)

Covered Individuals — Continuation Sheet
(a) Name of covered individual(s)
First name, middle initial, last name

(b) SSN or other TIN

(c) DOB (if SSN or other (d) Covered
TIN is not available) all 12 months

(e) Months of coverage

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

29

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

30

31

32

33

34

35

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40
Form 1095-B (2025)