COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS HAMILTON COUNTY, OHIO Enter: Plaintiff / Petitioner Obligee ( ) Obligor ( ) Date: Case No. -vs- File No. CSEA No. Defendant / Petitioner Obligee ( ) Obligor ( ) Judge ORDER SHARED LIABILITY FOR MEDICAL AND HEALTH CARE NEEDS (No Insurance Available) O.R.C. 3119.30 The Court finds that neither the Obligor nor Obligee has health insurance for the child(ren) available to them at a reasonable cost either through a group health plan offered by an employer or through any other group health insurance or health care policy, contract, or plan. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the Obligor and Obligee share liability for the cost of the medical and health care needs of the child(ren) according to the following formula: (a) Obligee shall be responsible for the first $100.00 per calendar year per child, for all (uninsured) medical, dental, hospital, prescription, optical, psychological, psychiatric and orthodontic expenses (designated “ordinary”), or other agreement or order, to wit: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (b) Costs of remaining (uninsured) (designated “extraordinary”) expenses, for the child(ren), shall be shared by Obligor and Obligee in the following amounts: Obligor 50% and Obligee 50% unless a cash medical support order is being paid by the Obligor to the Obligee or the Office of Child Support, then the Obligee is responsible for 100%, or other agreement or order, to wit: IT IS FURTHER ORDERED, ADJUDGED AND DECREED that Obligor and Obligee immediately inform the Court through the Hamilton County Child Support Enforcement Agency if health insurance coverage for the child(ren) becomes available at a reasonable cost through a group health insurance plan offered by the Obligor’s or Obligee’s employer or through any other group health insurance or health care policy, contract or plan available to the Obligor or Obligee. When such health insurance coverage becomes available to either DR 7.20 (Revised 03/16/2009) American LegalNet, Inc. www.FormsWorkFlow.com party, that party must obtain said insurance coverage and shall notify the appropriate agency of the nature and extent of said coverage. If the person required to obtain private health care insurance coverage for the children subject to this child support order obtains new employment, the agency shall comply with the requirements of section 3119.34 of the Revised Code, which may result in the issuance of a notice requiring the new employer to take whatever action is necessary to enroll the children in private health care insurance coverage provided by the new employer. Upon receipt of a notice by the child support enforcement agency that private health insurance coverage is not available at a reasonable cost, cash medical support shall be paid in the amount as determined by the child support computation worksheets in section 3119.022(3119.02.2) or 3119.023 (3119.02.3) of the Revised Code, as applicable. The child support enforcement agency may change the financial obligations of the parties to pay child support in accordance with the terms of the court or administrative order and cash medical support without a hearing or additional notice to the parties. Pursuant to 3119.30 (C) , you are required to notify the Court if health care coverage for the minor child(ren) becomes available at a reasonable cost through a group health insurance or health care policy, contract or plan offered by your employer or through any other available source. IT IS SO ORDERED. HAVE SEEN : Plaintiff/Petitioner/Obligor/Obligee Defendant/Petitioner/Obligor/Obligee Attorney for Plaintiff/Petitioner Attorney for Defendant/Petitioner INSTRUCTIONS TO THE CLERK: You are directed to mail a copy of this Order to the employer and to the Obligor and Obligee by Ordinary Mail, with proof of mailing, unless they have acknowledged receipt by signature above. DR 7.20 (Revised 3/09) 2 American LegalNet, Inc. www.FormsWorkFlow.com NOTIFICATION TO THE OBLIGOR/OBLIGEE: Obligor/Obligee is required to maintain health care coverage for the minor child(ren) at a reasonable cost through a group health insurance or health care policy, contract or plan offered by his/her employer or through any other available source. It is important for the well-being of your child(ren) that the best (and reasonable) health care coverage be maintained. Complete this document as appropriate immediately after the occurrence of any of the events listed and mail the original of this document to the office and address listed below. TO: Hamilton County Child Support Enforcement Agency 222 E. Central Pkwy Cincinnati, Ohio 45202 1. My employer (or new employer) now offers health care coverage for the minor child(ren) effective _________________________________, 20 . Employer’s name and address is: Insurer’s name, address, policy number, employee cost to cover child(ren) is: 2. I now have health care coverage available to the child(ren) from another source. State source, address, insurer, insurer’s address, policy number and cost to cover child(ren). Date: Obligor’s Signature Case No. Address File No. [ ] Check here if new address Daytime Phone No. CSEA NO. Obligee’s Signature Address [ ] Check here if new address Daytime Phone No. DR 7.20 (Revised 3/09) 3 American LegalNet, Inc. www.FormsWorkFlow.com