MEDICAL DATA SHEET (Plaintiffs -- Print and use this form to track dependent medical expenses.) You must complete this form if you wish to have Domestic Relations enforce medical provisions of your Support Order. Read the instructions below. PLAINTIFF NAME: ___________________ DEFENDANT NAME: ___________________ PACSES CASE # _____________ Date of Service Type of Service Child Total Bill Insurance (s) Reimbursements ______________________ Plaintiff Paid Defendant's Share ________________________________ DATE Balance PLAINTIFF’S SIGNATURE American LegalNet, Inc. www.FormsWorkflow.com Instructions for Claiming Unreimbursed Medical Expense Who can claim: Custodial parent for herself or himself (if covered by the order) and each child on the order. Not applicable when ongoing, predictable expenses are included within the order as a recurring monthly charge. Applicable order for these purposes would state the percentage each parent pays toward unreimbursed medical expense. What can be claimed: Annual unreimbursed medical expenses in excess of $250 per person. Medical expenses include insurance co-payments and deductibles and all expenses incurred for reasonably necessary medical services and supplies, including but not limited to surgical, dental and optical services, and orthodontia. Medical expenses do not include cosmetic, chiropractic, psychiatric or psychological services unless specifically directed in the order of court. This court does not recognize as medical expense for the present purpose such items as vitamins, non-prescription skin products, cough syrup, bandages, batteries, or other similar over-the-counter purchases. When to claim: When the expenses for an individual exceed $250 for an individual for the current year. Claims may be made thereafter as they occur or at the end of the calendar year. How to claim: Claims are to be filed directly by the custodial parent to the noncustodial parent. Do not send claim form or receipts to Domestic Relations. The claimant must use the attached form (or one similar) to list all items purchased, including those which establish that the $250 deductible threshold has been met. Copies of receipts to back up the items claimed should be attached. Be careful not to include two receipts for the same expense, for example, the register tape for a prescription and the MAC receipt for the same item. Also do not submit hospital statements which merely reflect the total cost, the amount accepted from the insurance carrier for the service, but no actual cost to the custodial parent. Claimant should keep a copy of the claim form and the original receipts. Non-custodial parent should remit directly to the custodial parent his court ordered share of the unreimbursed medical expenses (beyond the $250 deductible) in a timely manner, but not later than thirty days after receipt. Non-custodial parent should keep proof of payment. Do not remit to SCDU or Domestic Relations. When to involve Domestic Relations: When the custodial parent has followed the above procedure, but the non-custodial parent fails to remit payment. The custodial parent may file contempt of court against the non-custodial parent for failure to pay his or her share of unreimbursed medical expense as required under the terms of the court order. The burden is with the parties to present clear documentation to substantiate a claim of contempt or a defense thereto. Domestic Relations is not responsible for sorting through bills and receipts, nor for tallying expenses. American LegalNet, Inc. www.FormsWorkflow.com