MEDICAL EXPENSE NOTIFICATION To: ______________________________ ______________________________ ______________________________ ______________________________ Via: _____ _____ _____ _____ _____ Ordinary US Mail Certified Mail Registered Mail Hand Delivery Facsimile Medical service provider: (name and address) ______________________________ ______________________________ ______________________________ ______________________________ Amount of bill: Amount paid or covered by insurance: Uninsured portion: Applied to parent’s yearly $100.00 of medical expenses? Remaining expense to be paid: __________________ __________________ __________________ _____ Yes Amount applied: $__________ _____ No, parent has already paid first $100.00 for this child $__________________ Mother’s portion: $__________ Father’s portion: $__________ Invoice or copy of payment check attached: _____ Yes _____ No /If not, why not? _____________________________________________________________________________________ _____________________________________________________________________________________ Payment due to: Payment due no later than: _____ Parent _____ Provider ________________________ Notes: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (NOTICE: To the parent submitting medical bills: Please remember to submit to the other parent the medical bills which are applied to the first $100.00 per year per child which is your responsibility, even though the other parent owes no money on those bills. This will avoid confusion as to whether you have met your obligation when you do have bills which are the other parent’s responsibility. Please keep copies of this notice and the support documentation sent to the other party, for your records.) American LegalNet, Inc. www.FormsWorkflow.com