COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CLERMONT COUNTY, OHIO Section A Personal Information CASE NO. ________________ SETS NO. ________________ _________________________________ PRINT NAME ( G Mother G Father) ( )_________________________________ Home Telephone Number Street Address City State ( )_________________________________ Cell Phone Number Zip HEALTH INSURANCE QUESTIONNAIRE Check ALL applicable boxes and fill-in ALL blanks. G My child ( □ My child(ren) is/are covered by low-income government-assisted health care coverage (Healthy Start/Medicaid, etc.) __________________________________________________ Section B List of Plans I have the following private health insurance policies, contracts or plans to cover the child(ren) available to me: Name of Policy, contract or Plan Name of Insurance Company Entity/Group through which policy contract or plan is available __________________________________ _________________________________ __________________________________ No Private Insurance Section C __________________________________________________ G I DO NOT HAVE the child(ren) enrolled in private health insurance because: G Health insurance is not available through my employer or another group policy, contract or plan that will cover the chld(ren). G I declined enrollment of the child(ren) in health insurance available through my employer or another group policy, contract or plan, but I am enrolled in a policy, contract or plan for myself. G I am not yet eligible to enroll in private health insurance through employment or another group policy, contract, or plan, but I will become eligible on (month/date/year) ___/___/___. G I expect to enroll the child(ren) when I become eligible. G Other reason the child(ren) are not enrolled (explain) ______________________________ ________________________________________________________________________ Current Private Health Info. Section D __________________________________________________ G I DO HAVE the children enrolled in private health insurance through: G an individual (non-group) policy, contract or plan. G a group policy, contract or plan. Date child(ren) was/were enrolled in private health insurance: (month/date/year) ___/___/___. Provided through: G Employer G Current Spouse G Other: ____________________. Name of Policy Holder: Insurance Company Name:____________________ Policy Holder Address: Policy Holder Phone No.: ( Insurance Co. Claims Address:__________________ ) __ Insurance Co. Claims Phone No.: ( )____________ Name of policy, contract or plan:________________ Group No.: __________________________________ Identification/Subscriber No. __________________ Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Section E Accessibility of Care My child(ren) has/have primary care services (health care/laboratory services customarily provided by a general practitioner, internal medicine, family medicine physician, or pediatrician) accessible with this private insurance: G within 30 miles of the child(ren)’s home. G because the child(ren) lives in a geographic area where the residents customarily travel farther than 30 miles for their child(ren)’s primary care. G because primary care services are only accessible by public transportation. (Primary care services are accessible by public transportation and the person responsible for taking the child(ren) for primary care service is dependent upon public transportation). Section F Reasonableness of cost/best interest of children considerations _________________________________________________ The cost for private health insurance benefits that cover me and/or my child(ren) or will cover us when I am eligible is: (Do not include the amount that an employer or other person/entity pays for health insurance.) Single Coverage $ per month Single Coverage plus one $ per month Single Coverage plus two $ per month Family Coverage (unlimited dependents) $ per month Other: (explain): $ per month G I want to enroll/continue to have the child(ren) enrolled in the private health insurance plan in which I am currently enrolled/will become eligible to enroll in even if the cost exceeds 5% of my TOTAL ANNUAL GROSS INCOME (Health Insurance Maximum). Number of Dependents currently enrolled or who will be enrolled when I become eligible: _____ Name of Dependent Relationship to You ________________________ ______________________________ ________________________ ______________________________ ________________________ ______________________________ ________________________ In addition to my premium for health insurance, I must pay the following: Annual Deductible: $ Office Visits: $___________ Prescriptions: $ Urgent Care: $ __________ Emergency Room: $ Other: $ __________ Type of Coverage: G PPO G HMO G Traditional (unrestricted providers) G Other ________________________________ My private health insurance covers the following services: G Doctor’s Office Visits G Hospital Room/Board G Home Health Care G Emergency Care G Mental Health In-patient G Mental Health Out-patient G Medical Supplies G Substance Abuse Care G Durable Medical Equip. G Prescription Drugs G Diagnostic Testing G Laboratory nd G Surgery G 2 Surgical Opinion G Skilled Nursing Home G Other :__________________________________________________________________ _________________________________________________ Section G Certification ATTACH A COPY OF ALL PARTICIPANT CARDS, AND PRESCRIPTION CARDS. _________________________________________________ I, (print name), certify that the information I have provided on this HEALTH INSURANCE QUESTIONNAIRE is true and accurate to the best of my knowledge: Date: _________________________________________________ Signature ( G Mother G Father) 10/08 Form DR-409 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com