Eff. 7-1-07 APPENDIX A STANDARD HEALTH CARE ORDERS FOR MINOR CHILD(REN) PAYMENT OF EXTRAORDINARY EXPENSES FOR MINOR CHILD (REN) HURON COUNTY COMMON PLEAS COURT I. Standard Health Care Orders The minor child(ren) who are the subject of these orders are as follows: Name of Child Date of Birth ____________________________________ ____________________________________ ____________________________________ Name of Child Date of Birth ____________________________________ ____________________________________ ____________________________________ IT IS HEREBY ORDERED that the person(s) required to provide health insurance coverage for the minor child(ren) provide to the other parent, not later than thirty (30) days after the issuance of this order, information regarding the benefits, limitations, and exclusions of the coverage, copies of any insurance forms necessary to provide reimbursement, payment or benefits under the coverage, and a copy of any necessary insurance cards. IT IS FURTHER ORDERED that the party who has obtained coverage shall be reimbursed for out-of-pocket medical, optical, hospital, dental, or prescription expenses paid for each child and the health plan administrator that provides health insurance coverage for the children may continue making payment for medical, optical, hospital, dental, or prescription services directly to any health care provider in accordance with the applicable health insurance policy, contract or plan. IT IS FURTHER ORDERED that the person(s) required to provide health insurance coverage for the minor child(ren) shall designate the child(ren) as covered dependents under any health insurance policy, contract or plan for which the person contracts. IT IS FURTHER ORDERED that co-payments or deductible costs required under the health American LegalNet, Inc. www.FormsWorkflow.com insurance policy, contract or plan that covers the minor child(ren) pursuant to Court order shall be apportioned as follows: Mother______________________%; Father________________________%. IT IS FURTHER ORDERED that the employer of the person required to obtain health insurance coverage is required to release to the other parent, any person subject to an order issued under Section 3109.19 of the Revised Code, or the child support enforcement agency on written request any necessary information on the health insurance coverage, including the name and address of the health plan administrator and any policy, contract, or plan number, and to otherwise comply with this section and any order or notice issued under this section. IT IS FURTHER ORDERED if the person required to obtain health 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 health care insurance coverage provided by the new employer. IT IS FURTHER ORDERED that, if either parent or the legal custodian is eligible for and/or receives medical assistance (i.e, "Medicaid," etc.) under Revised Code Chapters 5111 or 5115 and the other parent has obtained health insurance coverage, the party eligible for medical assistance SHALL notify any physician, hospital or other provider of medical services for which medical assistance is available of the name and address of the other's insurer and of the number of the other's health insurance or health care policy, contract or plan. IT IS FURTHER ORDERED that the parties shall comply with any requirements ordered herein no later than thirty (30) days after the issuance of this order. II. Payment of Extraordinary Medical Expenses IT IS HEREBY ORDERED that, after payment of all extraordinary medical (i.e,, medical, dental, orthodontic, optical, surgical, hospital, prescription, psychiatric or psychological) expenses for said minor child(ren), from any and all available insurance coverage, then: A. The residential parent or, in the case of shared parenting, the parent entitled to receive court-ordered child support, shall pay the ordinary expenses totaling $100.00 per calendar year per child or less; B. The non-residential parent or, in the case of shared parenting, the parent required to pay court-ordered child support, shall pay a portion of the necessary extraordinary expenses totaling over $100.00 per calendar year per child as ordered within thirty (30) days of receipt or make acceptable arrangements with the health care provider for payment; C. Any extraordinary expenses shall be paid by the parents in proportion to their respective incomes as indicated on Line 16 of their child support computation worksheet as follows: Mother _______________________%; Father ___________________________%. American LegalNet, Inc. www.FormsWorkflow.com IT IS FURTHER ORDERED that neither parent shall cause the other to be charged or billed for expenses for the minor child(ren). IT IS FURTHER ORDERED that the residential parent and/or legal custodian shall promptly notify the other parent by written statement of the date of medical services provided to the minor child (ren), the cost of the service(s), the service(s) provided, and the identity of the service provider(s) for each child when medical expenses are incurred. NOTICE: No contempt for non-payment of medical bills will be entertained where an accounting for residential parent's share has not been given to the nonresidential parent. IT IS FURTHER ORDERED that, after the residential parent has paid said expense of $100.00 per year for a minor child, that parent shall provide the other parent any medical, dental, etc. bills incurred under this Order; further, the parent shall either reimburse the residential parent or pay the bill directly to the creditor within ten (10) days of receipt of said expense; further, each parent shall promptly notify the other of a child's illness or injury when the child is in his or her care. IT IS FURTHER ORDERED that, when it is determined that it is necessary for a minor child to have major medical, dental, orthodontic, optical, surgical, hospital, prescription, psychiatric or psychological expense not of an emergency nature which the non-residential parent is obligated to pay, then the residential parent shall immediately notify the other parent before authorizing treatment; further, that the other parent has a right to know the necessity for propos