Do you have a lease agreement, facility use application, contract or other license agreement? No, please fill out Section 1 and 2.On the day you apply for Medi-Cal assistance, you will be asked to complete some forms and to listen to an explanation of your rights and responsibilities. Your Form 1095B is proof of healthcare insurance for the IRS and does not require completion or submission to DHCS. Please keep this form for your records. Need help filling out the forms? The wording should be as follows: The City of San Bernardino, et al. Inland Empire Health Plan (IEHP) offers you easy access to useful reference materials and forms you may need. It's just one click away. Access forms and documents related to appeals, complaints, attestation, eligibility, privacy and more.