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Health Insurance Disclosure Affidavit - Ohio
| Health Insurance Disclosure Affidavit Form. This is a Ohio form and can be used in General Tuscarawas County (Court Of Common Pleas) . |
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IN THE COMMON PLEAS COURT OF COUNTY, OHIO DIVISION OF Case No. Plaintiff / Petitioner CSEA Account No. Family File No. V. JUDGE MAGISTRATE Defendant / Petitioner Health Insurance D isclosure Affidavit (HIDA) INSTRUCTIONS: This affidavit must be filed according to local rules of c ourt. You are required to disclose all requested information. You may need to consult your employer and insurer to comple te this form, There is a continuing duty to update the information contained in this form. If more space is needed, attach additional page(s). Please type or print legibly. Children Subject To Support Order Husband / Father / Other Name DOB SS# DOB SS# Street Residence Address Name DOB SS# Name Wife / Mother / Other DOB SS# DOB SS# Name Street Residence Address DOB SS# Form # (Revised ) HIDA Page 1 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 You are to disclose all requested information in the column for you and in the column for the other party. Part I Part II Husband / Father / Other Wife / Mother / Other Name Name Employer Employer Employer Address Employer Address Employer Phone Employer Phone Is Medicaid coverage available? Yes No Is Medicaid coverage available? Yes NoIs Medicare coverage available? Yes No Is Medicare coverage available? Yes NoIs family Health insurance available ei- Is family Health insurance available ei- ther through the employer or another ther through the employer or another Yes Nogroup or organization? Yes No group or organization? If not, is Private insurance available? Yes No If not, is Private insurance available? Yes NoIs coverage presently in effect? Yes No Is coverage presently in effect? Yes NoWho is presently covered? Name Relationship Name Relationship Insurer / Plan Name Phone Insurer / Plan Name Phone Address Address Policy / Group # Policy / Group # Other Policy / Group # (if another policy is available) Other Policy / Group # (if another policy is available) HIDA Page 2 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 You are to disclose all requested information in the column for you and in the column for the other party. Part I (Continued) Part II (Continued) Husband / Father / Other Wife / Mother / Other Is there a cost for coverage? Yes No Is there a cost for coverage? Yes No Special Instruction - The court requires both the Special Instruction - The court requires both the family cost and the Individual cost information. family cost and the Individual cost information. What is the annual cost for Family coverage? What is the annual cost for Family coverage? $ $ What is the annual cost for individual coverage? What is the annual cost for individual coverage? $ $ Is a Health insurance card available? Yes No Is a Health insurance card available? Yes NoAre insurance cards required for Are insurance cards required for services? Yes No services? Yes NoDoes the plan cover Hospitalization? Yes No Does the plan cover Hospitalization? Yes No Is there a deductible for services? Yes No Is there a deductible for services? Yes No If yes, what is the deductible? If yes, what is the deductible? Check One: Check One: $ Yr $ Per Visit Mo Yr Per Visit Mo Yes No Is there a co-payment required? Yes No Is there a co-payment required? If yes, what is the co-payment? If yes, what is the co-payment? Check One: Check One: $ Yr $ Per Visit Mo Yr Per Visit Mo NoDoes the plan cover doctor visits? Yes No Does the plan cover doctor visits? Yes Is there a deductible for services? Yes No Is there a deductible for services? Yes No If yes, what is the deductible? If yes, what is the deductible? Check One: Check One: $ Mo Yr $ Per Visit Mo Yr Per Visit Is there a co-payment required? Yes No Is there a co-payment required? Yes No If yes, what is the co-payment? If yes, what is the co-payment? Check One: Check One: $ Per Visit Mo Yr $ Visit Mo Yr Per HIDA Page 3 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4 You a re to dis close all reque s ted information in the column for you a nd in the column for the othe r pa rty Part I (Continued) Part II (Continued) Husband / Father/ Other Wife / Mother / Other Is a Prescription card available? Yes No Is a Prescription card available? Yes No Is there a co-payment required? Yes No Is there a co-payment required? Yes No If yes, what is the co-payment? If yes, what is the co-payment? $ Per Prescription $ Per Prescription Is Dental coverage available? Yes No Is Dental Coverage available? Yes NoInsurer / Plan Name Phone Insurer / Plan Name Phone Address Address Policy / Group # Policy / Group # Is there a c os t for Dental c overage? Yes No Is there a c os t for Dental coverage? Yes No S pecial Ins truction - The court requires both the family cost S pecial Ins truction - The court requires both the fa mily cost a nd the individual cost information. a nd the individua l cost informa tion. Wha t is the annua l cost for Fa mily Dental covera ge? What is the annua l cost for Fa mily Dental covera ge? $ $ What is the annual cost for individual Dental coverage? What is the annual cost for Individual Dental coverage? $ $ Is a Dental ins urance ca rd available? Yes No Is a Dental ins urance ca rd available? Yes NoAre Dental ins urance ca rds required Are Dental ins urance ca rds required Yes No Yes NoFor services ? For services ? Is Vision coverage av ailab le? Yes No Is Vision coverage av ailable? Yes NoInsurer / Plan Name Phone Insurer / Plan Name Phone Address Address Policy / Group # Policy / Group # HIDA Page 4 of 5 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 5 You are to disclose all requested information in the column for you and in the column for the other party. Part I (Continued) Part II (Continued) Husband / Father / Other Wife / Mother / Other Is there a cost for Vision coverage? Yes No Is there a cost for Vision coverage? Yes No Special Instruction - The court requires both the Special Instruction - The court requires both the family cost and the individual cost information. family cost and the individual cost information. What is the annual cost for Family Vision coverage? What is the annual cost for Family Vision coverage? $ $ What is the annual cost for Individual Vision coverage? What is the annual cost for Individual Vision coverage? $ $ Is Vision insurance card available? Yes No Is Vision insurance card available? Yes NoAre Vision insurance cards required Are Vision insurance cards requ
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