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STUDENT SERVICES 434F Page 2 REQUEST FOR PERMISSION TO DISCLOSE SCHOLASTIC RECORD DATA Date School Address Dear (parent/eligible student*): We have received a request from for (access to, copy of)
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Circle One - HCPS stands for Health Coverage Provider Supplement and is a form used to report health coverage information to the IRS.
Health coverage providers such as insurance companies, employers, and government agencies are required to file Circle One - HCPS.
Circle One - HCPS can be filled out electronically using the IRS ACA Information Returns (AIR) system.
The purpose of Circle One - HCPS is to report health coverage information to the IRS in compliance with the Affordable Care Act.
Circle One - HCPS requires information such as the name, address, and taxpayer ID number of the health coverage provider, as well as the months of coverage provided.
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