IN THE COMMON PLEAS COURT OF ________________ COUNTY, OHIO DIVISION OF _________________________________ Case No. Plaintiff / Pettitioner CSEA Account No. V. Family File No. JUDGE MAGISTRATE Defendant / Petitioner Health Insurance Disclosure Affidavit (HIDA) INSTRUCTIONS: This affidavit must be filed according to local rules of court. You are required to disclose all requested information. You may need to consult your employer and insurer to complete this form. There is a continuing duty to update the information contained in this form. If more space is needed, attach additional page(s). Please type or print legibly. Children Subject To Support Order Husband / Father / Other Form # ___(Revised ___) Name DOB SS# DOB SS# Street Residence Address Name DOB SS# Wife / Mother / Other Name DOB SS# DOB SS# Street Residence Address Name DOB Form # ___(Revised ___) SS# HIDA Page 1 of 5 American LegalNet, Inc. www.USCourtForms.com You are to disclose all requested information in the column for you and in the column for the other party. Part I Husband / Father / Other Part II Wife / Mother / Other Name Name Employer Employer Employer Address Employer Address Employer Phone Employer Phone Is Medicaid coverage available? {ADVANCE \u8}9Yes 9No Is Medicaid coverage available? {ADVANCE \u8}9Yes 9No Is Medicare coverage available? {ADVANCE \u8}9Yes 9No Is Medicare coverage available? {ADVANCE \u8}9Yes 9No Is family Health insurance available either through the employer or another group or organization? 9Yes 9No Is family Health insurance available either through the employer or another group or organization? {ADVANCE \u8} 9Yes 9No If not, is private insurance available? {ADVANCE \u8}9Yes 9No If not, is private insurance available? {ADVANCE \u8}9Yes 9No Is coverage presently in effect? {ADVANCE \u8}9Yes 9No Is coverage presently in effect? {ADVANCE \u8}9Yes 9No Who is presently covered? Who is presently covered? Name Insurer / Plan Name Address Relationship Phone Name Insurer / Plan Name Relationship Phone Address American LegalNet, Inc. www.USCourtForms.com Policy / Group # Policy / Group # Other Policy / Group # (If another policy is available) Other Policy / Group # (If another policy is available) HIDA Page 2 of 5 American LegalNet, Inc. www.USCourtForms.com You are to disclose all requested information in the column for you an in the column for the other party Part I (Continued) Husband / Father / Other Is there a cost for coverage? Part II (Continued) Wife / Mother / Other Yes No Is there a cost for coverage? Special Instruction: The court requires both the family cost and the Individual cost information. What is the annual cost for Family coverage? Yes No Special Instruction: The court requires both the family cost and the Individual cost information. What is the annual cost for Family coverage? $ $ What is the annual cost for individual coverage? What is the annual cost for individual coverage? $ $ Is a Health insurance card available? Yes No Is a Health insurance card available? Yes No Are insurance cards required for Services Yes No Are insurance cards required services? Yes No Does the plan cover Hospitalization? Yes No Does the plan cover Hospitalization? Yes No Is there a deductible for services? Yes No Is there a deductible for services? Yes No If yes, what is the deductible? If yes, what is the deductible? Check One: $ Per Check One: Visit Mo Is there a co-payment required? Yr Yes No $ Per Visit Mo Yr Yes Yes $ Per Mo Yr No Is there a deductible for services? Yes No If yes, what is the deductible? Check One: Visit Is there a co-payment required? Mo Yes Yr No $ Per Visit Mo Is there a co-payment required? If yes, what is the co-payment? Yr Yes No If yes, what is the co-payment? Check one: Per Visit Yes Check One: $ No Does the plan cover doctor visits? No No If yes, what is the deductible? Per Yes Check One: Does the plan cover doctor visits? Is there a deductible for services? $ Yr If yes, what is the co-payment? Check One: Per Mo Is there a co-payment required? If yes, what is the co-payment? $ Visit Check one: Visit Mo Yr $ Per Visit Mo Yr HIDA Page 3 of 5 American LegalNet, Inc. www.USCourtForms.com You are to disclose all requested information in the column for you and in the column for the other party Part I (Continued) Husband / Father / Other Is a Prescripstion card available? Is there a co-payment required? Part II (Continued) Wife / Mother / Other Yes No Yes No If yes, what is the co-payment? $ Is a Prescripstion card available? Yes Yes No Yes Is there a co-payment required? No No If yes, what is the co-payment? Per Perscription $ Is Dental coverage available? Yes Insurer / Plan Name No Phone Per Perscription Is Dental Coverage available? Insurer / Plan Name Address Address Policy / Group # Phone Policy / Group # Is there a cost for Dental coverage? Yes No Is there a cost for Dental coverage? Yes Special Instruction - The court requires both the family cost and the individual cost information. Special Instruction - The court requires both the family cost and the individual cost information. What is the annual cost for Family Dental coverage? No What is the annual cost for Family Dental coverage? $ $ What is the annual cost for Individual Dental coverage? What is the annual cost for individual Dental coverage? $ $ Is a Dental insurance card available? Yes No Is a Dental insurance card available? Yes No Are Dental insurance cards required For services? Yes No Are Dental insurance cards required For services? Yes No Is Vision coverage available? Yes No Is Vision coverage available? Yes No Insurer Plan Name Phone Insurer Plan Name Address Address Policy / Group # Phone Policy / Group # HIDA Page 4 of 5 American LegalNet, Inc. www.USCourtForms.com You are to disclose all requested information in the column for you and in the column for the other party Part I (Continued) Husband / Father / Other Is there a cost for Vision coverage? Part II (Continued) Wife / Mother / Other Yes No Special Instruction: The court requires both the family cost and the Individual cost information. What is the annual cost for Family Vision coverage? Is there a cost for Vision coverage? Yes No Special Instruction: The court requires both the family cost and the Individual cost information. What is the annual cost for Family Vision coverage? $ $ What is the annual cost for Individual Vision coverage? What is the annual cost for Individual Vision coverage? $ $ Is Vision insurance card availiable? Yes No Is Vision insurance card availiable? Yes No Are Vision insurance cards required for services? Yes No Are Vision insurance cards require for services ? Yes No Is COBRA insurance available? Is COBRA insurance available? (A continuation of present insurance coverage after termination of employment or marriage) (A continuation of present insurance coverage after termination of employment or marriage). If yes, at what cost? If yes, at what cost? $ Per Check One: Mo Yr $ Per Mo Yr Instructions: In a divorce or post decree action, only the party filing the HIDA is required to sign the oath. In a dissolution action, both parties must sign the oath. OATH OF AFFIANT(S) – SIGNATURE(S) MUST BE NOTARIZED I hereby swear or affirm that the information set forth in this health insurance disclosure affidavit above is true, complete and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification fo this document may also subject me to crimanal penaltiies for perjury (O.R.C.2921.11). _____________________________________________ AFFIANT – Husband / Father / Other ______________________________________________ AFFIANT – Wife / Mother / Other Sworn to and subscribed before me on this ________________ day of ______________, 20____ ___________________________________ Notary Public HIDA Page 5 of 5 American LegalNet, Inc. www.USCourtForms.com