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Health Insurance Affidavit - Ohio
| Health Insurance Affidavit Form. This is a Ohio form and can be used in Juvenile Division Clerk Of Courts Franklin County (Court Of Common Pleas) . |
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HEALTH INSURANCE DISCLOSURE AFFIDAVIT FRANKLIN COUNTY COMMON PLEAS COURT DIVISION OF DOMESTIC RELATIONS AND JUVENILE BRANCH ______________________________________ CASE NUMBER _____________________________ PLAINTIFF / PETITIONER COURT DATE _______________________________ SS# __________________________________ CHILDREN SUBJECT TO SUPPORT ORDER: DOB: ________________________________ NAME: __________________________ DOB: __________ ADDRESS: ___________________________ SS#:____________________________________ _____________________________________ NAME: __________________________ DOB: __________ SS#:____________________________________ NAME: __________________________ DOB: __________ _____________________________________ DEFENDANT / PETITIONER SS#:____________________________________ SS# __________________________________ NAME: __________________________ DOB: __________ DOB: ________________________________ SS#:____________________________________ ADDRESS: ___________________________ NAME: __________________________ DOB: __________ _____________________________________ SS#:____________________________________ INSTRUCTIONS PART I: Please disclose all requested information as it pertains to you YOUR NAME: ________________________________ EMPLOYER:__________________________________ EMPLOYER ADDRESS: ________________________ EMPLOYER PHONE: _______________________ _____________________________________________ ARE YOU CURRENTLY RECEIVING MEDICAID? ____ YES ___ NO / MEDICARE? _____ YES _____ NO DO YOU HAVE FAMILY HEALTH INSURANCE AVAI LABLE EITHER THROUGH YOUR EMPLOYER OR ANOTHER GROUP OR ORGANIZATION? ____YES ___ NO IS COVERAGE PRESENTLY IN EFFECT? ____YES ___NO WHO IS PRESENTLY COVERED? _________________________________ RELATIONSHIP ________________ _________________________________ RELATIONSHIP ________________ _________________________________ RELATIONSHIP ________________ _________________________________RELATIONSHIP ________________ _________________________________ RELATIONSHIP ________________ INSURER ________________________________________ PHONE _________________________________ ADDRESS _______________________________________ POLICY/ GROUP #____________________________ DO YOU PAY A PREMIUM FOR COVERAGE? _________ YES ____________ NO WHAT IS THE PREMIUM FOR FAMILY COVERAGE? $_____________________ PER month/year (circle one) WHAT IS THE PREMIUM FOR INDIVIDUAL COVERAGE ? $_____________________ PER month/year (circle one) (Page 1 of 3) <<<<<<<<<********>>>>>>>>>>>>> 2 HEALTH INSURANCE DISCLOSURE AFFIDAVIT IS A HEALTH INSURANCE CARD AVAILABLE? __________ YES ___________ NO ARE INSURANCE CARDS REQUIRED FOR SERVICES? __________ YES ___________ NO DOES YOUR PLAN COVER HOSPITALIZATION? __________ YES ___________ NO IS THERE A DEDUCTIBLE FOR SERVICES? __________ YES ___________ NO IF YES, WHAT IS THE DEDUCTIBLE? $_________________ per VISIT/MONTH/YEAR (circle one) IS THERE A CO-PAYMENT REQUIRED? __________ YES ___________ NO IF YES, WHAT IS THE CO-PAYMENT? $_________________ per VISIT/MONTH/YEAR (circle one) DOES YOUR PLAN COVER DOCTOR VISITS ? __________ YES ___________ NO IS THERE A DEDUCTIBLE FOR SERVICES? __________ YES ___________ NO IF YES, WHAT IS THE DEDUCTIBLE? $_________________ per VISIT/MONTH/YEAR (circle one) IS THERE A CO-PAYMENT REQUIRED? __________ YES ___________ NO IF YES, WHAT IS THE CO-PAYMENT? $_________________ per VISIT/MONTH/YEAR (circle one) IS A PRESCRIPTION CARD AVAILABLE? _________ _ YES ___________ NO IS THERE A CO-PAYMENT REQUIRED? __________ YES ___________ NO IF YES, WHAT IS THE CO-PAYMENT? $_________________ per PRESCRIPTION DOES YOUR PLAN INCLUDE DENTAL COVERAGE? __________ YES ___________ NO DOES YOUR PLAN INCLUDE VISION COVERAGE? __________ YES ___________ NO IS COBRA COVERAGE AVAILABLE? __________ YES ___________ NO (COVERAGE AVAILABLE TO YOU AFTER TERM INATION OF EMPLOYMENT OR MARRIAGE) IF YES, AT WHAT COST TO YOU ? $_________________ per MONTH/YEAR (circle one) INSTRUCTIONS PART II: Please disclose all requested information as it pertains to the other party NAME OF OTHER PARTY: _______________________________EMPLOYER:_______________________________ EMPLOYER ADDRESS: ________________________ EMPLOYER PHONE: ____________________ _____________________________________________ IS HE/SHE CURRENTLY RECEIVING MEDICAID? ____ YES ___ NO / MEDICARE? _____ YES _____ NO DOES HE/SHE HAVE FAMILY HEALTH INSURANCE AVAILABLE EITHER THROUGH HIS/HER EMPLOYER OR ANOTHER GROUP OR ORGANIZATION? ____YES ___ NO IS COVERAGE PRESENTLY IN EFFECT? ____YES ___NO WHO IS PRESENTLY COVERED? _________________________________ RELATIONSHIP ________________ _________________________________ RELATIONSHIP ________________ _________________________________ RELATIONSHIP ________________ _________________________________RELATIONSHIP ________________ _________________________________ RELATIONSHIP ________________ (PAGE 2 OF 3) <<<<<<<<<********>>>>>>>>>>>>> 3 HEALTH INSURANCE DISCLOSURE AFFIDAVIT INSURER ________________________________________ PHONE _________________________________ ADDRESS _______________________________________ POLICY/ GROUP #____________________________ DOES HE/SHE PAY A PREMIUM FOR COVERAGE? _________ YES ____________ NO WHAT IS THE PREMIUM FOR FAMILY COVERAGE? $_____________________ PER month/year (circle one) WHAT IS THE PREMIUM FOR INDIVIDUAL COVERAGE ?$_____________________ PER month/year (circle one) IS A HEALTH INSURANCE CARD AVAILABLE? __________ YES ___________ NO ARE INSURANCE CARDS REQUIRED FOR SERVICES? __________ YES ___________ NO DOES HIS/HER PLAN COVER HOSPITALIZATION ? __________ YES ___________ NO IS THERE A DEDUCTIBLE FOR SERVICES? __________ YES ___________ NO IF YES, WHAT IS THE DEDUCTIBLE? $_________________ per VISIT/MONTH/YEAR (circle one) IS THERE A CO-PAYMENT REQUIRED? __________ YES ___________ NO IF YES, WHAT IS THE CO-PAYMENT? $_________________ per VISIT/MONTH/YEAR (circle one) DOES HIS/HER PLAN COVER DOCTOR VISITS ? __________YES ___________ NO IS THERE A DEDUCTIBLE FOR SERVICES? __________ YES ___________ NO IF YES, WHAT IS THE DEDUCTIBLE? $_________________ per VISIT/MONTH/YEAR (circle one) IS THERE A CO-PAYMENT REQUIRED? __________ YES ___________ NO IF YES, WHAT IS THE CO-PAYMENT? $_________________ per VISIT/MONTH/YEAR (circle one) IS A PRESCRIPTION CARD AVAILABLE? _________ _ YES ___________ NO IS THERE A CO-PAYMENT REQUIRED? __________ YES ___________ NO IF YES, WHAT IS THE CO-PAYMENT? $_________________ per PRESCRIPTION DOES HIS/HER
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