Ohio > County (Court Of Common Pleas) > Lake > Domestic Relations
Health Care Determination - Ohio
| Health Care Determination Form. This is a Ohio form and can be used in Domestic Relations Lake County (Court Of Common Pleas) . |
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COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS LAKE COUNTY, OHIO ___________________________________ PLAINTIFF vs. : : JUDGE _______________________________ : : ___________________________________ DEFENDANT HEALTH CARE DETERMINATIONS [Cash Medical Support: O.R.C. §3119.30(C)] [Private Health Insurance: O.R.C. §3119.302] CASE NO. _____________________________ Cash Medical Support The Child Support Obligor's total annual gross income (Line 7a, Child Support Computation Worksheet) is less than [OR] greater than or equal to 150% of the federal poverty guideline for an individual ($10,890 x 150% = $16,335.00 for the year 2011). When private health insurance is not being provided, the Obligor's Cash Medical Support obligation is $ ____________ per month ($______________per month per child), plus 2% processing charge. (Line 31, Child Support Computation Worksheet-Sole Residential Parent or Shared Parenting Order or Line 29, Child Support Computation Worksheet-Split Parental Rights and Responsibilities) A list of any private health insurance policies, contracts or plans available to the parties including a description of any private health insurance in which the Child Support Obligor, the Child Support Obligee, and the children are enrolled (Private Health Insurance Questionnaire) is attached hereto. Private Health Insurance Neither party has Private Health Insurance available to cover the minor children. One or both of the parties has/have Private Health Insurance available to cover the minor children. a) Accessibility The private health insurance available to the Mother and/or the Father: Mother Father provides primary care services within thirty miles from the residence of the child(ren) subject to the child support order. is accessible because residents in part or all of the child(ren)'s immediate geographic area customarily travel farther distances than thirty miles for primary care services. 2-4-11 EXHIBIT 1 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com is accessible because primary care services are only available to the child(ren) by public transportation. b) Reasonableness The cost of private health insurance to the Mother is $________________ (cost of adding the child(ren) to existing coverage or difference between self-only and family coverage), which: exceeds the Health Insurance Maximum (line 7b of Child Support Computation Worksheet). does not exceed the Health Insurance Maximum (line 7b of Child Support Computation Worksheet). The cost of private health insurance to the Father is $________________ (cost of adding the child(ren) to existing coverage or difference between self-only and family coverage), which: exceeds the Health Insurance Maximum (line 7b of Child Support Computation Worksheet). does not exceed the Health Insurance Maximum (line 7b of Child Support Computation Worksheet). (Check applicable box(es) if cost of Private Health Insurance EXCEEDS the Health Insurance Maximum) Both parties agree that: Mother shall obtain or maintain private health insurance that exceeds the health insurance maximum for that parent. Father shall obtain or maintain private health insurance that exceeds the health insurance maximum for that parent. both Mother and Father shall obtain or maintain private health insurance that exceeds the health insurance maximum for that parent. Mother has requested to obtain or maintain the private health insurance that exceeds the health insurance maximum for that parent. Father has requested to obtain or maintain the private health insurance that exceeds the health insurance maximum for that parent. The following private health insurance coverage is available to the Mother and/or Father through a group policy, contract, or plan at a reasonable cost: Insurer: _________________________________ _________________________________ Available to: Mother Father Mother Father Mother and Father should be designated as the Health Insurance Obligor(s), until further order of Court. 2-4-11 EXHIBIT 1 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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