Michigan > Statewide > Domestic Relations > Support
Notice To Enroll Dependent On Health Care Coverage (Federal) OMB-1210-0113 - Michigan
| Notice To Enroll Dependent On Health Care Coverage (Federal) Form. This is a Michigan form and can be used in Support Domestic Relations Statewide . |
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NATIONAL MEDICAL SUPPORT NOTICE PART A NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement Income Security Act of 1974 (ERISA), and for State and local government and church plans, sections 401(e) and (f) of the Child Support Performance and Incentive Act of 1998. Issuing Agency: __________________________ Issuing Agency Address: ___________________ ________________________________________ Date of Notice: _______________________ Case Number: ________________________ Telephone Number: ___________________ FAX Number: _________________________ Court or Administrative Authority: ___________________________ Date of Support Order: _____________________ Support Order Number: ____________________ _____________________________________) Employer/Withholder's Federal EIN Number _____________________________________) Employer/Withholder's Name _____________________________________) Employer/Withholder's Address _____________________________________) Custodial Parent's Name (Last, First, MI) _____________________________________) Custodial Parent's Mailing Address _____________________________________) Child(ren)'s Mailing Address (if different from Custodial Parent's) _____________________________________) _____________________________________) _____________________________________) Name, Mailing Address, and Telephone Number of a Representative of the Child(ren) Child(ren)'s Name(s) __________________________ __________________________ __________________________ DOB SSN _______ ________ _______ ________ _______ ________ RE* _______________________________________ Employee's Name (Last, First, MI) _______________________________________ Employee's Social Security Number _______________________________________ Employee's Mailing Address _______________________________________ Substituted Official/Agency Name and Address Child(ren)'s Name(s) ____________________________ ____________________________ ____________________________ DOB SSN _________ __________ _________ __________ _________ __________ The order requires the child(ren) to be enrolled in [ ] any health coverages available; or [ ] only the following coverage(s): __Medical; __Dental; __Vision; __Prescription drug; __Mental health; __Other (specify):______________________________ THE PAPERWORK REDUCTION ACT OF 1995 (P.L. 104-13) Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. OMB control number: 0970-0222 Expiration Date: 02/29/2008. American LegalNet, Inc. www.FormsWorkflow.com EMPLOYER RESPONSE If either 1, 2, or 3 below applies, check the appropriate box and return this Part A to the Issuing Agency within 20 business days after the date of the Notice, or sooner if reasonable. NO OTHER ACTION IS NECESSARY. If neither 1, 2, nor 3 applies, forward Part B to the appropriate plan administrator(s) within 20 business days after the date of the Notice, or sooner if reasonable. Check number 4 and return this Part A to the Issuing Agency if the Plan Administrator informs you that the child(ren) is/are enrolled in an option under the plan for which you have determined that the employee contribution exceeds the amount that may be withheld from the employee's income due to State or Federal withholding limitations and/or prioritization. 1. Employer does not maintain or contribute to plans providing dependent or family health care coverage. 2. The employee is among a class of employees (for example, part-time or non-union) that are not eligible for family health coverage under any group health plan maintained by the employer or to which the employer contributes. 3. Health care coverage is not available because employee is no longer employed by the employer: Date of termination: _______________________________ Last known address: _______________________________ Last known telephone number: _______________________ New employer (if known): __________________________ New employer address: _____________________________ New employer telephone number: ____________________ 4. State or Federal withholding limitations and/or prioritization prevent the withholding from the employee's income of the amount required to obtain coverage under the terms of the plan. Employer Representative: Name: ___________________________________ Telephone Number: _____________ Title: ___________________________________ Date: ________________ EIN (if not provided by Issuing Agency on Notice to Withhold for Health Care Coverage): _________________ American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS TO EMPLOYER This document serves as notice that the employee identified on this National Medical Support Notice is obligated by a court or administrative child support order to provide health care coverage for the child(ren) identified on this Notice. This National Medical Support Notice replaces any Medical Support Notice that the Issuing Agency has previously served on you with respect to the employee and the children listed on this Notice. If the employee already has enrolled the child(ren) in health care coverage, the employer should contact the issuing agency to provide coverage information. The document consists of Part A - Notice to Withhold for Health Care Coverage for the employer to withhold any employee contributions required by the group health plan(s) in which the child(ren) is/are enrolled; and Part B - Medical Support Notice to the Plan Administrator, which must be forwarded to the administrator of each group health plan identified by the employer to enroll the eligible child(ren), or completed by the employer, if the employer serves as the health plan administrator. EMPLOYER RESPONSIBILITIES 1. If the individual named above is not your employee, or if family health care coverage is not available, please complete item 1, 2, or 3 of the Employer Response as appropriate, and return it to the Issuing Agency. NO FURTHER ACTION IS NECESSARY. If family health care coverage is available for which the child(ren) identified above may be eligible, you are required to: a. Transfer, not later than 20 business
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