Form 802m Medical Support Order (10/2014) Page 1 of 8 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff Name DOB V. Defendant Name DOB MEDICAL SUPPORT ORDER PLAINTIFF PLAINTIFF'S EMPLOYER or of Funds First - Name Last Name Name Mailing Address Mailing Address City State Code , City State Zip Code Phone Number P hone Number Social Security Number Email Address DEFENDANT DEFENDANT'S EMPLOYER or Source of Funds First - Name Last Name Name Mailing Address Mailing Address City State Zip Code , City State Zip Code Phone Number Phone Number Social Security Number Email Address CHILDREN WHO ARE SUBJECT OF THIS ORDER First Name Last Name Date of Birth Grade Social Security Number American LegalNet, Inc. www.FormsWorkFlow.com Form 802m Medical Support Order (10/2014) Page 2 of 8 II. TYPE OF HEARING, DEFAULT OR STIPULATION This order is entered: after default hearing (when one or more parties fail to appear) upon approval of the parties (stipulation filed) pursuant to 15 V.S.A. 247660(d) Parties Present: Plaintiff Plaintiff's Attorney Defendant Defendant222s Attorney OCS Other: Plaintiff was not present, but Received notice by personal service on: Received notice by certified mail restricted delivery on: Signed an acceptance of service on: Other: Defendant was not present, but Received notice by personal service on: Received notice by Signed an acceptance of service on: Other: FINDINGS AND BASIS OF ORDER II. PARENTAGE Parentage has been established as follows: The following child(ren) was/were born or adopted during the marriage: A Parentage Order for the following child(ren): was issued on by the Vermont Superior Court Other: An action has been brought under 15 V.S.A. 247293 and there is a legal presumption of parentage for the following child(ren) Basis for the presumption: The alleged parent failed to submit without good cause to court ordered genetic testing. The alleged parents have voluntarily acknowledged parentage under the laws of this state or any other state, by filling out and signing a voluntary acknowledgement of parentage form and filing the completed and witnessed form with the department of health. The probability that the alleged parent is the biological parent exceeds 98 percent as established by a scientifically reliable genetic test. III. American LegalNet, Inc. www.FormsWorkFlow.com Form 802m Medical Support Order (10/2014) Page 3 of 8 III. PARENTAL RIGHTS AND RESPONSIBILITIES A. Plaintiff Defendant has assigned medical support rights to the state. B. The parties do not seek a parental rights and responsibilities order. C. The parties do not seek a child support order. D. Additional information: IV. MEDICAL SUPPORT This is the result of a medical support worksheet which is attached and incorporated as findings in this order. A. The parties are ordered to pay medical support as follows: Child(ren) are presently covered by state or federally provided health insurance in Mother222s Father222s household. This health insurance coverage shall be maintained for the child(ren) for so long as the child(ren) remain eligible for current coverage. The Plaintiff Defendant is ORDERED to provide and maintain private health insurance for the minor child(ren) as long as the cost of health insurance is deemed reasonable. Private health insurance is currently unavailable to either party. The shall pay a cash contribution toward the cost of health coverage as follows: $Per Beginning: Private health insurance is currently unavailable to either parent at a reasonable cost. If private health insurance becomes available to either parent at a reasonable cost, that parent shall be responsible for providing and maintaining health insurance for the minor child(ren). Either parent may request a hearing to determine whether the cost of health insurance is reasonable. B. Current Medical Support Coverage Health Insurance: Policy or Certificate Number: Name of Subscriber: Relationship to Child(ren): Plan Name: Plan Address: Subscriber ID Number: C. Child(ren)'s Out of Pocket Medical Expenses Medical or other health expenses that are unreimbursed by insurance (including but not limited to expenses for eye, dental, mental health, health plan deductible) shall be shared as follows: 1) The parties shall share unreimbursed expenses as follows: Plaintiff % Defendant % 2) Additional Provisions: American LegalNet, Inc. www.FormsWorkFlow.com Form 802m Medical Support Order (10/2014) Page 4 of 8 D. Additional Medical Support Provisions 1. If employed, a parent under a medical support order shall notify his/her employer of such obligation, in writing, within 10 days of the date of this order. 2. If self-employed or unemployed, a parent under a medical support order shall notify his/her health care insurer of such obligation in writing within 10 days of the date of this order. 3. A parent is liable for any unreimbursed health care costs of the child(ren) that result from that parent's failure to give notice/obtain insurance as ordered above, which accrues between the date of this order and the date that the order is modified by the Court. 4. If a parent has health insurance through an entity other than his/her employer, that parent shall be responsible for maintaining that insurance and complying with any notice requirements under the policy in effect. Failure to do so will make the parent liable for paying any unreimbursed health care expenses that accrue between the date of this order and the date this order is modified by the Court. 5. If a parent pays a health expense of a child subject to this order and the other parent receives reimbursement from insurance for the expense, the reimbursement shall be sent to the parent who advanced payment, within 30 days of receipt. If the child(ren) also have Medicaid coverage, payment is to be sent to: Office of Health Access, 312 Hurricane Drive, Suite 201, Williston, VT 05495-2806, within 30 days. 6. The parties shall provide each other with copies of bills for health expenses and documentation of insurance determination within 30 days of receipt. The parent who maintains insurance shall also provide the other parent with a health insurance card, claim forms and a list of benefits and restrictions within 10 days of the date of this order. V. ARREARS ON PAST DUE MEDICAL SUPPORT/REPAYMENT PROVISIONS A. Arrears Owed Office of Child Support Plaintiff Defendant shall pay the Office for Child Support as follows: $ per on a judgment of $ as of The judgment consists of the following past due amounts: $ Other: $ B. Arrears Owed to Plaintiff Defendant Plaintiff Defendant shall pay the other party as follows: $ per on a judgment of $ as of The judgment consists of the following past due amounts: $ Other: $ American LegalNet, Inc. www.FormsWorkFlow.com Form 802m Medical Support Order (10/2014) Page 5 of 8 C. Arrears Owed to Other Agency Plaintiff Defendant shall pay to as follows: $ per on a judgment of $ as of The judgment consists of the following past due amounts: $ Other: $ VII. Method of Payment A. WAGE WITHHOLDING ORDER Any employer of Plaintiff Defendant shall deduct the following sum from his/her wages: $ per This deducted amount shall be paid directly to: OFFICE OF CHILD SUPPORT PO BOX 1310 WILLISTON, VT 05495 B. DIRECT PAYMENT Based upon Stipulation of the parties Evidence presented at hearing Plaintiff Defendant shall make payments directly to the Office for Child Support as follows: $per This deducted amount shall be paid directly to: OFFICE OF CHILD SUPPORT PO BOX 1310 WILLISTON, VT 05495 Plaintiff Defendant shall make payments directly to the other party as follows: $ per C. Additional Orders: American LegalNet, Inc. www.FormsWorkFlow.com Form 802m Medical Support Order (10/2014) Page 6 of 8 VII. DURATION OF MEDICAL SUPPORT A. This order shall remain in effect unless and until it is changed or discontinued by further order of the Court or by operation of law. B. Unless otherwise specified, a party's support obligation will continue beyond a child's eighteenth birthday if the child is enrolled in, but has not completed high school, unless otherwise specified. C. If wage withholding is ordered and an ar