Explanation Of Medical Bills Form {29}

FORM 29 - EXPLANATION OF HEALTH CARE BILLS. This form is used in the Summit County Court of Common Pleas, Domestic Relations Division, to document and seek reimbursement for a child’s medical expenses in cases involving shared financial responsibility between parties—typically following a divorce, dissolution, or custody order. This form requires the party submitting the claim to provide detailed information about each health care expense, including the date of treatment, the name of the service provider, the type of services rendered, and the total cost of the bill. It also records how much was paid by insurance, how much was paid by each party, any unpaid balance, and the specific amount being requested from the other party. The form must be accompanied by supporting documentation such as the original medical bills, explanation of benefits (EOB) forms from insurance providers, and proof of any payments made. It is intended to ensure transparency and accountability in the division of a child’s medical costs and must be brought to court at the time of the hearing. The form is approved under Ohio Civil Rule 84. www.FormsWorkflow.com