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Request For Health Care Expense Payment FOC 13 - Michigan
|Request For Health Care Expense Payment Form. This is a Michigan form and can be used in General Domestic Relations Statewide .||
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Original - Obligor 1st copy - Requesting partyApproved, SCAO 2nd copy - for court as needed STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT REQUEST FOR HEALTH CARE COUNTY EXPENSE PAYMENT Friend of the Court address Telephone no.Plaintiff Defendant v INSTRUCTIONS FOR REQUESTING PARTY: The following is important information should you later seek to obtain the friend of the courts help to enforce payment of health careexpenses (medical, dental, and other health care expenses). 1. Your court order must require the other party to pay a portion of health care expenses. 2. The expense must exceed any amounts your child support order requires as a prerequisite for enforcement. 3. You must submit your request for payment to the other party within 28 days of either the date insurance has paid on the expenses or the date insurance denies payment. 4. If you and the other party reach an agreement concerning the expenses, the agreement must be in writing, list the expenses to be paid, state the total amount to be paid, and provide a schedule for payment. Both parties must sign the agreement. 5. The bills must be presented to the friend of the court on or before the following: 1 year after the expense was incurred; or 6 months after the insurers final denial of coverage for the expense (as long as all measures necessary to submit the claim to insurance were completed within 2 months after the expense was incurred); or 6 months after a default in a repayment agreement as set forth above. You will need to fill out a second form to request enforcement. 6. In the event it is necessary for the friend of the court to enforce payment of the expenses, you must have supporting bills and receipts for the expenses you list. You will be responsible for establishing the expenses and their necessity. Please bring your documentation to all court hearings where medical expenses may be discussed. 7. Attach a copy of all bills and insurance notifications to this form. 8. You must keep a copy of this form and all attachments for the friend of the court to use in the event enforcement action is necessary. Obligors name and address TO: Complete expenses incurred on the other side of this form. FOC 13 (6/03) REQUEST FOR HEALTH CARE EXPENSE PAYMENT MCL 552.531, MCL 552.602<<<<<<<<<********>>>>>>>>>>>>> 2The following expenses have been incurred for the health care of a minor child for whom you are obligated to provide health care support. Name of Child Name of Date of Type of Total Amt. Paid Balance Obligors Amt. Owed Receiving Service Medical Provider Service Service Medical by Due* % by Cost Insurance ObligorI declare that the above statements are true to the best of my information, knowledge, and belief and that on this date I mailed a copy of this Request for Health Care Expense Payment to the obligor at his or her last known address. Date Signature *Balance due means balance owed after payment by insurance and any adjustments to the total medical cost.