COURT OF COMMON PLEAS{PRIVATE } DIVISION OF DOMESTIC RELATIONS HAMILTON COUNTY, OHIO Enter Plaintiff / Petitioner xxx-xxSS # -vsDOB ( ) Obligor ( ) Obligee Judge Date Case No. File No. CSEA No. Defendant / Petitioner xxx-xxSS # ( ) Obligor ( ) Obligee Judge QUALIFIED MEDICAL CHILD SUPPORT ORDER (O.R.C. 3119.30) DOB HEALTH INSURANCE PLAN: _________________________________________________________________________________ PARTICIPANT 1: NAME:_________________________________________________________________________________ Obligor/Obligee Address:_________________________________________________________________________________ City: ___________________________________ State: _______________________ Zip: _____________________ PARTICIPANT 1: EMPLOYER:________________________________________________________________________________ Address:_________________________________________________________________________________ City: ___________________________________ State: _______________________ Zip: _____________________ HEALTH INSURANCE PLAN: (If applicable): ____________________________________________________________________ PARTICIPANT 2: NAME:_________________________________________________________________________________ Obligor/Obligee Address:_________________________________________________________________________________ City: ___________________________________ State: _______________________ Zip: _____________________ PARTICIPANT 2: EMPLOYER:________________________________________________________________________________ Address:_________________________________________________________________________________ City: ___________________________________ State: _______________________ Zip: _____________________ ALTERNATE Name(s): ____________________________________________________________________________________ RECIPIENT(S): and DOB (Child/ren) __________________________________________________________________________________ Address:_____________________________________________________________________________________ City: ___________________________________ State: _______________________ Zip: _________________________ DR 7.17 (Revised 03/16/2009) American LegalNet, Inc. www.FormsWorkFlow.com WHEREAS, the Court finds that health insurance coverage for the child(ren) named as Alternate Recipient(s) is available to the Participant at a reasonable cost and that the Participant has been ordered to secure/maintain health insurance coverage for the child(ren). IT IS HEREBY ORDERED THAT: 1. The following group health insurance and health care policies, contracts and plans are available at a reasonable cost to the Participants (include name of insurer that issues each policy, contract or plan): 2. Participant shall provide the insurer within thirty (30) days from the date of this order with a copy of this Order and promptly shall complete the necessary enrollment forms or other documents necessary to designate the Alternate Recipient(s) listed above as dependents eligible for coverage by the Health Insurance Plan identified above in the form and to the same extent coverage is available to the Participant and other dependents of the Participant in the Health Insurance Plan. Participant shall also within thirty (30) days of the issuance of this order, furnish written proof to the Hamilton County Child Support Enforcement Agency, 222 E. Central Pkwy Cincinnati, Ohio that the coverage has been obtained, that the insurer has been provided with a copy of this order, and that the other party has been provided with all documents/information as set forth in paragraph 3 below. 3. Participant shall supply the other party with (a) insurance forms necessary to receive payment. Reimbursement or other benefits; (b) necessary insurance cards; and (c) information regarding the benefits, limitations and exclusions of the coverage of the Health Insurance Plan or any successor plan. 4. Obligor/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, including co-payments and deductibles (designated "ordinary"). The remaining uninsured expenses (designated "extraordinary"), including additional co-payments and/or deductibles under the Health Insurance Plan for the Alternate Recipient(s), shall be shared by the parties as follows: Obligor - 50% and Obligee - 50% or other agreement or order: 5. Any reimbursements for out-of-pocket medical, optical, hospital, dental, prescription or other reimbursable expenses covered under the Health Insurance Plan or any successor plan and paid for on behalf of the Alternate Recipient(s) insured child(ren) shall be made directly to: Obligor/Obligee: Name: Address: The insurer may continue to make payments for medical, optical, hospital, dental or prescription services directly to any health care provider in accordance with the Health Insurance Plan. 6. Participant shall be responsible for any premiums charged by the insurer for coverage of the Alternate Recipient(s) under the Health Insurance Plan. 7. Pursuant to O.R.C. 3119.30, this order is binding upon the Obligor and Obligee, their employers, and any insurer that provides health insurance for them or their child(ren). 8. If Participant fails to provide health insurance coverage for the child(ren) within thirty (30) days as ordered or otherwise to comply within thirty (30) days with any other provision of this Order, the CSEA shall notify the Court in writing of the failure to comply and the Court shall issue an order to the employer to take whatever action is necessary to make application to enroll Participant in any available group health insurance policy or health care policy with coverage for the child(ren) who are subject of the child support order, to submit a copy of this Order for health insurance coverage to the insurer at the time that the employer makes application to enroll the child(ren) in the health insurance or health care policy contract or plan, and if the application is accepted, to deduct any additional amount from earnings necessary to pay the additional cost for that health insurance coverage. 9. Any insurer who receives a copy of an order issued under O.R.C. 3119.30 shall comply with that section, and any order issued under that section, regardless of the residence of the child(ren). 10. During the time that this Order is in effect, the employer who is the