Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Motion For Reimbursement Of Medical Expenses Form. This is a Kansas form and can be use in 7th Judicial District (Douglas County) Local District Court.
Loading PDF...
Tags: Motion For Reimbursement Of Medical Expenses, Kansas Local District Court, 7th Judicial District (Douglas County)
DISTRICT COURT TRUSTEE
PS-10
SEVENTH JUDICIAL DISTRICT
111 EAST 11TH STREET, UNIT 101
LAWRENCE, KS 66044-2966
785-832-5315
Fax: 785-838-2408
Pro Se
Motion for Reimbursement of Medical Expenses
**Please read these instructions in their entirety before you begin!**
The following information is provided to assist you in obtaining a judgment for court-ordered
payment of medical expenses that are due and owing to you. Your court order must specifically set forth
the percentage that each party must pay for unreimbursed medical expenses in order for you to obtain a
judgment. You must provide proof that you have asked the other party in writing to reimburse you for
their share of the unpaid medical expenses A hearing cannot be held until your motion has been filed
and all of the steps have been completed.
The following documents (included in this packet) must be filled out and filed with the court when
seeking a reimbursement of medical expenses. Fill out the documents using a typewriter, or print legibly
in black or blue ink.
1. Motion for Reimbursement of Medical Expenses
2. Notice of Hearing and Certificate of Mailing
3. Return of Service for Certified Mail
Follow the steps below in the order given. Check each one off as you complete it to
properly file your motion with the court.
1. Motion for Reimbursement of Medical Expenses.
a.
b.
c.
d.
Fill out the motion completely, making sure you sign your name where indicated.
Attach supporting documentation to your completed Motion for Reimbursement.
(Copies of all unpaid medical bills for which you seek reimbursement; copy of the
letter where you asked the other party to pay their court-ordered portion; and copy
of the divorce decree which states how unpaid medical expenses are to be divided
between the parties)
The Certificate of Mailing portion should include the names and addresses of the
following:
i. Opposing party/ex-spouse;
ii. Opposing party/ex-spouse’s attorney of record, if any.
Make 4 copies of the Motion for Reimbursement of Medical Expenses and 3 copies of the
supporting documentation. (4 copies if the opposing party has an attorney)
1
American LegalNet, Inc.
www.FormsWorkFlow.com
e.
f.
Staple the original Motion for Reimbursement of Medical Expenses to the originals of the
supporting documentation that you are providing.
Staple the remaining copies of the Motion for Reimbursement to each remaining copy of
the supporting documentation. Write “Chamber copy” at the top of one of the copies.
2. Notice of Hearing and Certificate of Mailing.
a.
b.
Fill out the Notice of Hearing and Certificate of Mailing, with the exception of the hearing
date and time. The Certificate of Mailing section should include the same people that you
wrote on the certificate of mailing on your Motion for Reimbursement of Medical
Expenses.
Make 3 copies of the completed Notice of Hearing. (4 copies if the opposing party has an
attorney)
4. Filing your Motion and Obtaining a Hearing Date.
a.
b.
Go to the Clerk of the District Court office in the basement of the Judicial and Law
Enforcement Center at 111 East 11th Street, Lawrence, KS to file your motion. Bring
originals and all copies with you.
Give the clerk at the counter the original and all copies of the Motion for Reimbursement
of Medical Expenses.
The clerk will file-stamp the original and all copies of your Motion for Reimbursement of
Medical Expenses. They will keep the original for the court file and give you back all of
the copies.
c.
Go to the Judge Pro Tem office for a hearing date and time. Their office is located in the
south hallway on the main floor of the building. Give the administrative assistant the
“Chamber copy” of your Motion for Reimbursement of Medical Expenses and the original
and all copies of your Notice of Hearing and Certificate of Mailing.
The administrative assistant will give you a hearing date and time and write it on the
original and all copies of the Notice of Hearing. The assistant will keep one copy and give
the rest back to you.
d.
Go back downstairs to the Clerk of the District Court office and give the original and all
copies of the Notice of Hearing and Certificate of Mailing to the clerk for filing. The clerk
will keep the original Notice of Hearing for the court file and give you back all the filestamped copies.
2
American LegalNet, Inc.
www.FormsWorkFlow.com
5. Serving the Opposing Party.
You must mail the remaining copies by certified mail to the opposing party and their attorney of
record, if any. You should do this on the same day that you file the Notice of Hearing with the Clerk of
the District Court. Failure to mail the copies and provide proof of service will result in your motion being
dismissed.
a.
b.
c.
Keep one copy of the Motion for Reimbursement of Medical Expenses and one copy of
the Notice of Hearing for yourself.
Mail one copy of the Motion for Reimbursement of Medical Expenses (with all
attachments) and one copy of the Notice of Hearing to the opposing party/ex-spouse by
certified mail.
Mail one copy of the Motion for Reimbursement of Medical Expenses (with all
attachments) and one copy of the Notice of Hearing to the opposing attorney of record, if
any, by certified mail.
6. Filing the Return of Service for Certified Mail.
After you mail your Motion for Reimbursement of Medical Expenses and Notice of Hearing by
certified mail to the required parties, you will have to wait for the Return of Service ( “green card”) to be
returned to you by the post office. Once you receive the green card(s), follow the steps below to prove to
the court you served your motion properly.
a.
b.
c.
d.
e.
Fill out the Return of Service for Certified Mail.
Attach the green card(s) to the middle of the page where indicated.
Make one copy for your file.
Bring the original Return of Service for Certified Mail to the Clerk of the District Court
office in the basement of the Judicial & Law Enforcement Center at 111 East 11th Street,
Lawrence, KS.
Hand the document to the clerk at the counter for filing. The clerk will keep the document
so that it can be placed in your court file as proof that you completed all the steps
necessary to properly file your Motion for Reimbursement of Medical Expenses.
PLEASE REMEMBER!! It is up to you to get the correct papers filed and proper service
completed in order for a hearing to be held at its assigned hearing date and time.
3
American LegalNet, Inc.
www.FormsWorkFlow.com
IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS
In the Matter of
,
Petitioner,
vs.
,
)
)
)
)
)
)
)
)
Case No. DG
Division __
Respondent.
MOTION FOR REIMBURSEMENT OF MEDICAL EXPENSES
COMES NOW
and moves the Court to grant a judgment against
(Your name)
for reimbursement of medical expenses for the following reasons:
(Opposing party’s name)
A.
I am asking the court to grant a judgment against
the medical expenses, which total $
for
% of
.
B.
Attached is a copy of the Divorce Decree/Property Settlement Agreement, which states the
percentage of medical expenses that each party shall be responsible for.
C.
Attached are copies of medical bills that HAVE/HAVE NOT been paid.
D.
Attached is proof of my request for payment of the above expenses from the opposing party, but such
request has been refused.
WHEREFORE, I move the Court to enter a judgment for reimbursement of medical expenses
pursuant to the current support order of the Court.
Your signature
Pro se
Address
Phone
CERTIFICATE OF MAILING
A copy of this Motion for Reimbursement of Medical Expenses has been sent by Certified Mail/Return
Receipt Requested to (Petitioner/Respondent) and their attorney of record at the following addresses:
Date
(Your signature again here)
American LegalNet, Inc.
www.FormsWorkFlow.com
IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS
In the Matter of
,
Petitioner,
vs.
,
)
)
)
)
)
)
)
)
Case No. DG
Division __
Respondent.
NOTICE OF HEARING
PLEASE TAKE NOTE that the Motion for Reimbursement of Medical Expenses has
,
been set for hearing before the Judge Pro Tem on the _____ day of
20
, at
a.m., or as soon thereafter on said date as the Court can hear the same,
in the Pro Tem Division Courtroom of the Judicial & Law Enforcement Center, 111 East 11th
Street, Lawrence, Kansas.
Your signature
Pro se
CERTIFICATE OF MAILING
I hereby certify that on the
day of
, 20
, I caused a true
and correct copy of this Notice of Hearing to be mailed by Certified Mail, Return Receipt Requested,
addressed to the following:
Your signature
Pro se
American LegalNet, Inc.
www.FormsWorkFlow.com
IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS
IN THE MATTER OF
,
Petitioner,
and
,
Respondent.
)
)
)
)
)
)
)
)
)
Case No. DG
Division __
RETURN OF SERVICE FOR CERTIFIED MAIL
State of Kansas
County of Douglas
)
)
)
ss.
The undersigned, being duly sworn, states: I have served a Motion for Reimbursement of Medical
Expenses and Notice of Hearing on the Petitioner/Respondent, and their attorney of record, if any, and the following
Return for Receipt of Service was served on the litigant by certified mail on
, 20
, at
the time and place as listed on the attached card.
(When you receive the signed green card back
from the other party, tape it here.)
Check here if service by certified mail was refused. (If refused, I certify that I sent a true copy of the
motion by first-class mail after the certified letter was refused.)
Your signature
Subscribed and sworn to before me on this
Pro se
day of
, 20
.
Notary Public
My commission expires:
American LegalNet, Inc.
www.FormsWorkFlow.com
