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Health Insurance Disclosure Affidavit - Ohio
| Health Insurance Disclosure Affidavit Form. This is a Ohio form and can be used in Domestic Relations Huron County (Court Of Common Pleas) . |
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Court Form 2 Supplement Eff. 7/1/08 IN THE COMMON PLEAS COURT OF HURON COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS : Plaintiff/Petitioner (1) : : V. : Case No. CSEA No. Family File No. ________________________ JUDGE JAMES W. CONWAY Defendant/Petitioner (2)/Respondent : MAGISTRATE BRADLEY E. SALES : HEALTH INSURANCE DISCLOSURE AFFIDAVIT (HIDA) Instructions: This affidavit must be filed according to Local Rules of Court. You are required to disclose all requested information. You may need to consult your employer to complete this form. There is a continuing legal 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 DOB Street Residence Address SS# Name DOB Name DOB SS# SS# Wife/Mother/Other DOB Street Residence Address SS# Name DOB Name DOB SS# SS# You are to disclose all requested information in the column for you and in the column for the other party. Health Insurance Disclosure Affidavit Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com Part I Husband/Father/Other Name Employer Employer Address Name Employer Part II Wife/Mother/Other Employer Address Employer Phone Employer Phone Is Medicaid coverage available? Is Medicare coverage available? Is family health insurance available either through the employer or another group or organization? If not, is private insurance available? Is coverage presently in effect? W ho is presently covered? Name GYes GNo GYes GNo Is Medicaid coverage available? Is Medicare coverage available? Is family health insurance available either through the employer or another group or organization? If not, is private insurance available? Is coverage presently in effect? W ho is presently covered? Name GYes GNo GYes GNo GYes GNo GYes GNo GYes GNo GYes GNo Relationship GYes GNo GYes GNo GYes GNo GYes GNo Relationship Insurer/Plan Name Address Phone Insurer/Plan Name Address Phone Policy/Group # Other Policy/Group # (if another policy is available) Policy/Group # Other Policy/Group # (if another policy is available) Health Insurance Disclosure Affidavit Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com You are to disclose all requested information in the column for you and in the column for the other party. Part I Husband/Father/Other Is there a cost for coverage? GYes GNo Special Instruction - The court requires both the family cost and the individual cost information. W hat is the annual cost for family coverage? $ W hat is the annual cost for individual coverage? $ Part II Wife/Mother/Other Is there a cost for coverage? GYes GNo Special Instruction - The court requires both the family cost and the individual cost information. W hat is the annual cost for family coverage? $ W hat is the annual cost for individual coverage? $ Is a health insurance card available? Are insurance cards required for service? Does the plan cover hospitalization? Is there a deductible for services? If yes, what is the deductible? Check one: Per GVisit GYes GNo GYes GNo GYes GNo GYes GNo Is a health insurance card available? Are insurance cards required for service? Does the plan cover hospitalization? Is there a deductible for services? If yes, what is the deductible? GYes GNo GYes GNo GYes GNo GYes GNo $ GMo. GYr. $ Check one: Per GVisit GMo. GYr. Is there a co-payment required? GYes GNo Is there a co-payment required? If yes, what is the co-payment? Check one: Per GVisit GYes GNo If yes, what is the co-payment? $ Check one: Per GVisit GMo. GYr. $ GMo. GYr. Does the plan cover doctor visits? GYes GNo Does the plan cover doctor visits? GYes GNo Is there a deductible for services? GYes GNo If yes, what is the deductible? Check one: Per GVisit Is there a deductible for services? GYes GNo If yes, what is the deductible? $ Check one: Per GVisit GMo. GYr. $ GMo. GYr. Is there a co-payment required? GYes GNo Is there a co-payment required? If yes, what is the co-payment? Check one: Per GVisit GYes GNo If yes, what is the co-payment? $ Check one: Per GVisit GMo. GYr. $ GMo. GYr. Health Insurance Disclosure Affidavit Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com You are to disclose all requested information in the column for you and in the column for the other party. Part I Husband/Father/Other Is a prescription card available? GYes GNo Is a co-payment required? If yes, what is the co-payment? $ Insurer/Plan Name Address Part II Wife/Mother/Other Is a prescription card available? Is a co-payment required? If yes, what is the co-payment? $ Per Prescription GYes GNo Phone GYes GNo Per Prescription GYes GNo Phone Is dental coverage available? Is dental coverage available? Insurer/Plan Name Address Policy/Group # Policy/Group # Is there a cost for dental coverage? GYes GNo Is there a cost for dental coverage? GYes GNo Special Instruction - The court requires both the family cost and the individual cost information. What is the annual cost for family dental coverage? $ What is the annual cost for individual dental coverage? $ Special Instruction - The court requires both the family cost and the individual cost information. What is the annual cost for family dental coverage? $ What is the annual cost for individual dental coverage? $ Is a dental insurance card available? GYes GNo Is a dental insurance card available? GYes GNo Are dental insurance cards required for service? GYes GNo Is vision coverage available? Insurer/Plan Name Address Are dental insurance cards required for service? GYes GNo Is vision coverage available? Insurer/Plan Name Address GYes GNo Phone GYes GNo Phone Policy/Group # Policy/Group # Health Insurance Disclosure Affidavit Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com You are to disclose all requested information in the column for you and in the column for the other party. Part I Husband/Father/Other Is there a cost for vision coverage? Part II Wife/Mother/Other Is there a cost for vision coverage? GYes GNo GYes GNo Special Instruction - The court requires both the family cost and the individual cost information. What is the annual cost for family vision coverage? $ What is the annual cost for individual vision coverage? $ Special Instruction - The court requires both the family cost and the individual cost information. What is the annual cost for family vision coverage? $ What is the annual cost for individual vision coverage? $ Is a vision insurance card available? GYes GNo Is a vision ins
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