Fill and Sign the 416 545 Art 5 B Form

F.C.A. § § 416, 545, Art 5-B; Form 4-10D.R.L. §240(l). (Qualified Medical Child Support Order-- Non-IV-D Cases) 8/2010At a term of the Family Court of the State of New York, held in and for the County ofat , New York onPRESENT: Hon. Judge/Support Magistrate---------------------------------------------------------------In the Matter of a Proceeding for Supportunder Article of the Family Court ActDocket No.QUALIFIED MEDICALCHILD SUPPORT ORDERPetitioner (Non-IV-D Cases)S.S.#: xxxx-xx- Address: -against-RespondentS.S.#: xxxx-xx --------------------------------------------------------------NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY, AFTER A COURT HEARING, RESULT IN YOUR COMMITMENT TO JAIL FOR A TERM NOT TO EXCEED SIX MONTHS, FOR CONTEMPT OF COURT.IF THIS ORDER WAS ENTERED BY A JUDGE, THE ORDER MAY BE APPEALEDPURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT. THAT SECTION PROVIDES THAT ANAPPEAL FROM THAT ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BYTHE APPELLANT IN COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FORTHE CHILD UPON THE APPELLANT, OR 35 DAYS FROM THE DATE OF MAILING OF THE ORDERTO THE APPELLANT BY THE CLERK OF COURT, WHICHEVER IS EARLIEST. IF THIS ORDER WAS ENTERED BY A SUPPORT MAGISTRATE, SPECIFIC WRITTENOBJECTIONS TO THIS ORDER MAY BE FILED WITH THIS COURT WITHIN 30 DAYS OF THE DATETHE ORDER WAS RECEIVED IN COURT OR BY PERSONAL SERVICE, OR IF THE ORDER WASRECEIVED BY MAIL, WITHIN 35 DAYS OF THE MAILING OF THE ORDER.This Qualified Medical Child Support Order (QMCSO) orders and directs that the minorchild(ren):Name: Date(s) of Birth Last 4 Digits of Soc. Sec.#: Mailing Address: Form 4-10 Page 2are entitled to be enrolled in and receive the benefits for which the legally responsible relative namedbelow is eligible, under the group health plan specified below in accordance with Section 609 of theFederal Employee Retirement Income Security Act.The Participant (legally responsible relative) is:Name: Last 4 Digits of Soc. Sec.# : Mailing Address:The custodial parent is:Name: Last 4 Digits of Soc. Sec. #: Mailing Address:The group health plan subject to this order is:ORDERED that coverage shall include all plans covering any medical, dental, optical andprescription drugs and health care services or other health care benefits that may be provided for thedependent(s) named above for which the Participant is eligible. ORDERED that the above-named minor children shall be enrolled immediately and thecoverage shall continue as available until [specify]: .ENTER:DATED Judge/Support MagistrateCheck applicable box:G Order mailed on [specify date(s) and to whom mailed]: G Order received in court on [specify date(s) and to whom given]: TO:[Health Insurer]NOTICE: Pursuant to Section 5241 of the Civil Practice Laws and Rules, if an employer,organization or group health plan fails to enroll eligible dependents or to deduct from the debtor'sincome the debtor's share of the premium, such employer, organization or group health planadministrator shall be jointly and severally liable for all health-related or health care expenses incurredon behalf of the debtor's dependents named in the execution while such dependents are not so enrolledto the extent of the insurance benefits that should have been provided under such execution.The group health plan is not required to provide any type or form of benefit or option nototherwise provided under the group health plan except to the extent necessary to meet the requirementsof Section 1396(g-1) of Title 42 of the United States Code.