Ohio > County (Court Of Common Pleas) > Clermont > Domestic Relations
Mother Health Care DR-402 - Ohio
| Mother Health Care Form. This is a Ohio form and can be used in Domestic Relations Clermont County (Court Of Common Pleas) . |
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Mother shall designate (names and dates of birth of children) as dependents eligible for health insurance coverage in the group health insurance policy offered (i) by Mothers employer or (ii) through another group health care policy, contract, or plan available to Mother within thirty days from the date of this order, which insurer is (list insurers name and policy number). Mother shall supply Father with (i) information regarding the benefits, limitations, and exclusions of the coverage, (ii) insurance forms necessary to receive reimbursement, payment, or other benefits, and (iii) any necessary insurance cards within thirty days of the issuance of this order. The health plan administrator that provides the health insurance coverage for the children may continue making payment for medical, optical, hospital, dental, or prescription services directly to any health care provider in accordance with the applicable health insurance policy, contract, or plan. (Mother/Father) shall be responsible for the first $100.00 per year per child of any medical, dental, orthodontia, optical, prescription, psychiatric, psychological, or counseling expenses not paid by insurance. Any additional such expenses, including co-payments and/or deductibles under the health insurance plan for the child(ren), shall be divided between the parties in accordance with each partys income as reflected on the attached child support worksheet as follows: Mother shall pay percent and Father shall pay percent. Mother shall be liable to Father for any medical expenses incurred for the child(ren) as a result of Mothers failure to comply with this order. Mother and Father shall comply with ORC 3119.30 through 3119.58. If Mother obtains new employment Clermont County CSE shall comply with the requirements of ORC 3119.34 which mae of a notice requiring the new emply result in the issuanc oyer to take whatever action is necessary to enroll the child(ren) in health care insurance coverage provided by the new employer. Mother shall immediately notify Father and Clermont County CSE if her health insurance coverage through the above-named insurer is changed or terminated for any reason. Form DR-402 American LegalNet, Inc. www.USCourtForms.com
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