C33 Eff. 1/15 PAGE _____ OF _____. EXPLANATION OF MEDICAL BILLS NAME OF CHILD DATE OF TREATMENT (CHRONOLOGICAL ORDER) NAME OF SERVICE PROVIDER (DOCTOR, DENTIST, HOSPITAL) TOTAL BILL INSURANCE PAID AMOUNT OF BILL UNPAID AMOUNT DUE FROM EX-SPOUSE TOTALS PAGE TOTAL ____________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com TOTAL AMOUNT OF CLAIM SUGGESTIONS FOR PRESENTATION OF MOTIONS FOR PAYMENT OF MEDICAL BILLS FOR CHILDREN 1. Provide client with copy of Explanation of Medical Bills form. Require client to complete this form. 2. Prepare an affidavit for client, as applicable: A) B) Client has sent copies of bills to ex spouse; dates sent Client has sent copies of bills to ex spouse; dates sent and dates returned Client has sent copies of bills to ex spouse; ex spouse has not paid or acknowledged receipt of bills Client has sent copies of bills to ex spouse; ex spouse has told client he/she will not pay Any other information pertinent to case C) D) E) 3. Do not file copies of bills with motion. Just file the explanation of bills. 4. Attorney should have a copy set of bills, proof of insurance paid, and proof of client=s payment for opposing party and the court at the hearing, or mail to opposing counsel in advance. Moving party must be able to identify bills, date of service, purpose for treatment, total bill, amount paid by insurance, amount paid by movant, and amount sought from ex spouse. 5. American LegalNet, Inc. www.FormsWorkFlow.com