HEALTH CARE EXPENSE WORKSHEET CHILD'S NAME: DATE OF SERVICE: NAME OF PROVIDER: WHAT EXPENSE WAS FOR : ORIGINAL TOTAL CHARGE BY PROVIDER: AMOUNT INSURANCE PAID: UNINSURED AMOUNT: EACH PARENT=S PERCENTAGE OF UNINSURED HEALTH CARE EXPENSES UNDER COURT ORDER EACH PARENT=S PORTION OF TOTAL UNINSURED BILL (multiply the amount in the gray box above by each parent=s percentage) SUBTRACT any amounts already paid to the health care provider by each parent ON THIS BILL AMOUNT EACH PARENT OWES TO THE PROVIDER AND/OR TO THE OTHER PARENT AS REIMBURSEMENT (if the number is negative, then that parent is owed money by the other parent) Name:_______ ________ % $ -$ =$ = $ $ $ Name:________ ________% $ -$ =$ Prepared by: Provided to other parent on: How Provided: ***COPIES OF THE HEALTH CARE BILL AND ANY AEXPLANATION OF BENEFITS@ FROM THE INSURANCE COMPANY MUST BE ATTACHED*** Page 1 of 1 FORM 8.00 (Eff. 3/1/2017) American LegalNet, Inc. www.FormsWorkFlow.com