CHECKLIST FOR DEMAND FOR HEALTH CARE PAYMENT Did you use all insurance? Did you notify the other parent and provide copy of bill/receipt? Did you check the service dates after the one year limit? Is the $200 minimum met? Are you using ink? Did you fill in all the blanks, including case number? Did you organize and list all your bills by date? Do the bills have all the information we need? See the Instructions, Page 2. Did you attach copies of all the bills you listed on the form? Is everything legible? Did you date and sign the form? DO NOT FILL IN THE BOTTOM OF THE FORM AFTER YOUR SIGNATURE. Thank you for your cooperation. FD/FOC4045c (07/03) CHECKLIST FOR DEMAND FOR HEALTH CARE PAYMENT American LegalNet, Inc. www.FormsWorkflow.com