Figure: 1 TAC §55.120(b) Request for Review of National Medical Support Notice (NMSN) To: Office of the Attorney General Medical Support Unit PO Box 1328 Austin, TX 78767-1328 Telephone Number: (800) 522-2421 Fax Number: (855) 329-6676 From: Name: _________________________ Street Address: _________________________ City: _____________________ State: _____ Zip: _________ Telephone Number: ______________________ Cause Number: _____________________ OAG Number: _____________________ Custodial Parent's Name: _____________________ Child(ren) Name: ______________________ ______________________ ______________________ ______________________ I, _______________________ (obligor/employee), contest the National Medical Support Notice (NMSN) sent to my employer, ______________________________ (name of employer), on or about _________ (date), and request an administrative review based upon the following mistake(s) of fact: ______________________________________________________________________________ It has been within 30 calendar days from the date of notice of issuance of the National Medical Support Notice. I understand: I will receive notice of the date, time, and place of the review within 10 days of the Office of the Attorney General (OAG) receiving this request; The review may be in person or over the telephone; My employer and I must comply with the terms of the NMSN during this review period; At the end of the review, which will be completed within 30 days of receipt of this request, the OAG may issue a revised NMSN, terminate the NMSN, or send me notice of determination that the NMSN is proper and should remain in effect as previously issued; and If the OAG does not revise or terminate the NMSN, I may request a hearing with the court of continuing jurisdiction to resolve any issue in dispute. ______________________________ Obligor/Employee Signature Form 1669 Date: _________ March 2016 American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR REVIEW OF NATIONAL MEDICAL SUPPORT NOTICE (NMSN)