Health Insurance Form Failure to provide information will delay the completion of your return and require additional correspondence.Due to changes in the tax law you are now required to provide information in regards to your health insurance coverage for the year 2019 to your tax preparer. Please answer the below questions: Please note you may be receiving a tax document from your health insurance provider. Please provide us with a copy of that document and complete the below items as well.Did anyone in your family receive health insurance through the federal or state run insurance market place? (Select one)YesNoif yes, please list the members who were covered by this insuranceDid you have health insurance coverage for the full 2019 year? (Select one)YesNoIf no, please list dates you were covered if any:Did your spouse have health insurance coverage for the full 2019 year? (Select one)YesNoIf no, please list dates you were covered if any:Did your children (up to the age of 26 even if not currently a dependent) have health insurance coverage for the full 2019 year? (Select one)YesNoIf no, please list dates you were covered if any:Please list children your above statement is in regards to and any additional notes/discrepanciesPrinted NameSignature/DateSubmitSave as Draft