Ohio > County (Court Of Common Pleas) > Ashland > Domestic Relations
Health Care Expense Worksheet 8.00 - Ohio
| Health Care Expense Worksheet Form. This is a Ohio form and can be used in Domestic Relations Ashland County (Court Of Common Pleas) . |
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HEALTH CARE EXPENSE WORKSHEET CHILD'S NAME: ________________________________ DATE OF SERVICE: NAME OF PROVIDER: WHAT EXPENSE WAS FOR : ORIGINAL TOTAL CHARGE BY PROVIDER: AMOUNT INSURANCE PAID: UNINSURED AMOUNT: EACH PARENT'S PERCENTAGE OF UNINSURED HEALTH CARE EXPENSES UNDER COURT ORDER EACH PARENT'S PORTION OF TOTAL UNINSURED BILL (multiply the amount in the gray box above by each parent's percentage) SUBTRACT any amounts already paid to the health care provider by each parent ON THIS BILL AMOUNT EACH PARENT OWES TO THE PROVIDER AND/OR TO THE OTHER PARENT AS REIMBURSEMENT (if the number is negative, then that parent is owed money by the other parent) MOTHER ________ % $ -$ =$ $ -$ =$ = $ $ $ FATHER ________% Prepared by (check one): 9 MOTHER 9 FATHER Provided to other parent on: __________________ How provided: ___________________ ***COPIES OF THE HEALTH CARE BILL AND ANY "EXPLANATION OF BENEFITS" FROM THE INSURANCE COMPANY MUST BE ATTACHED*** Page 1 of 1 FORM 8.00 (Eff. 3/1/2011) American LegalNet, Inc. www.FormsWorkFlow.com
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