Request of IRS Form 1095-B

MediExcel Health Plan Coverage

Your MediExcel Health Plan Coverage is considered “minimum essential coverage” for tax purposes. MediExcel Health Plan provides all subscribers with IRS Form 1095-B, which lists information needed to report on your income tax return as proof that you and your eligible dependents had qualifying health coverage (referred to as “minimum essential coverage”) for some or all of 2022.

Receive IRS Form by March 3^rd, 2023

If you have not received your IRS Form 1095-B from MediExcel Health Plan by March 3^rd, 2023, please let us know by completing the form below with as much information as possible. If limited information is provided, we may ask for verification of identity before sending you your Form 1095-B.

Member ID Number*

Last Name of Subscriber*

First Name of Subscriber*

Last Four Digits of SSN*

Date of Birth of Subscriber (MM-DD-Year)*

E-mail Address*

US Mailing Address*

Indicate how you want to receive your Form 1095-B*

--------- US Postal Service Mail E-mail Pick up in Chula Vista Office Pick up in Tijuana Office

US Postal Service Mail

If we have questions, how do you prefer to be contacted?*

--------- US Postal Service Mail E-mail Telephone

Other Information*

Send

You may also send the above information to us by:

• E-mail: 1095@mediexcel.com
• Mail:
  • MediExcel Health Plan
  • 750 Medical Center Ct. Suite 2
  • Chula Vista, CA 91911

Processing Time. Once all necessary information has been received, Form 1095-B will
be e-mailed within 48 hours or within 3 business days if mailed.