NATIONAL MEDICAL SUPPORT PART B MEDICAL SUPPORT NOTICE TO PLAN ADMINISTRATOR This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement Income Security Act of 1974 (ERISA), and for State and local government and church plans, sections 401(e) and (f) of the Child Support Performance and Incentive Act of 1998 (CSPIA). Receipt of this Notice from the Issuing Agency constitutes receipt of a Medical Child Support Order under applicable law. The rights of the parties and the duties of the plan administrator under this Notice are in addition to the existing rights and duties established under such law. The information on the Custodial Parent and Child(ren) contained on this page is confidential and should not be shared or disclosed with the employee. NOTE: For purposes of this form, the Custodial Parent may also bet he employee when the State opts to enforce against the Custodial Parent. Issuing Agency: Office of the Attorney General Child Support Division - Medical Support Unit Issuing Agency Address: P.O. Box 1328 Austin, Texas 78767-1328 Notice Date: CSE Agency Case Identifier: Telephone Number: (800) 522-2421 FAX Number: (855) 329-6676 , , County, Texas Order Date: Order Identifier: Document Tracking Identifier: Employer web site: www.employer.texasattorneygeneral.gov See NMSN Instructions: www.acf.hhs.gov/programs/css/resource/national-medicalsupport-notice-form Court or Administrative Authority: ___________________________________________ Employer/Withholder's Federal EIN Number RE* ___________________________________________ Employee's Name (Last, First, MI) ________________________________________________ Employer/Withholder's Name __________________________________________ Employee's Social Security Number _____________________________________________________ Employer/Withholder's Address >