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STATE OF VERMONT SUPERIOR COURT Addison Unit Unit Docket No. Plaintiff Name DOB FAMILY DIVISION v. Defendant Name Other Party Name: DOB Other Party Name: MEDICAL SUPPORT ORDER PLAINTIFF First-Name PLAINTIFF'S EMPLOYER or Source of Funds Last Name Name Mailing Address Mailing Address City Zip Code State State Zip Code Phone Number Phone Number Social Security Number DEFENDANT First-Name Email Address DEFENDANT'S EMPLOYER or Source of Funds Last Name Name Mailing Address Mailing Address City , State Zip Code Phone Number City State Zip Code Phone Number Social Security Number Email Address CHILDREN WHO ARE SUBJECT OF THIS ORDER First Name City Last Name 400-00802M - Medical Support Order (07/2019) Date of Birth Grade Social Security Number Page 1 of 8 II. TYPE OF HEARING, DEFAULT OR STIPULATION This order is entered: ☐ after default hearing (when one or more parties fail to appear) ☐ upon approval of the parties (stipulation filed) ☐ pursuant to 15 V.S.A. §660(d) certified mail restricted delivery on: Parties Present: ☐ Plaintiff ☐ Plaintiff's Attorney ☐ Defendant ☐ Defendant’s Attorney ☐ OCS ☐ Other: ☐ Plaintiff was not present, but ☐ Received notice by personal service on: ☐ Received notice by certified mail restricted delivery on: ☐ Signed an acceptance of service on: ☐ Other: ☐ Defendant was not present, but ☐ Received notice by personal service on: ☐ Received notice by personal service on: ☐ Signed an acceptance of service on: ☐ Other: FINDINGS AND BASIS OF ORDER II. PARENTAGE ☐ The parties executed a Voluntary Acknowledgement of Parentage or Acknowledgment of Parentage, which was filed with the Vermont Department of Health and has not been rescinded or challenged, pursuant to 15C V.S.A. §304-309. ☐ There is a legal presumption for the child(ren): ☐ The child(ren) was/were born or adopted during the marriage/civil union; List Child(ren) Name(s)__________________________________________________________________________ ☐ The child(ren) was/were born within 300 days of the date the marriage/civil union terminated, either by divorce, annulment or operation of law; List Child(ren) Name(s)__________________________________________________________________________ ☐ The parties married each other after the birth of the child(ren) they asserted parentage of the child, and agreed to be and are named as parents of the child(ren) on the birth certificate; List Child(ren) Name(s)__________________________________________________________________________ ☐ The parties resided in the same household with the child(ren) from the child(ren)’s birth through the first two years of their life, including temporary periods of absence, and both parties openly held out the child(ren) as the non-birth parent’s child(ren). List Child(ren) Name(s)__________________________________________________________________________ ☐ The parties are intended parents of the child(ren) pursuant to a gestational carrier agreement. List Child(ren) Name(s)_____________________________________________________________________________ ☐ A Parentage Order for the child(ren) was issued on _________ by ______________________________ ☐ The Vermont Superior Court ☐ Other:______________________________________________ List Child(ren) Name(s)___________________________________________________________________________ 400-00802M - Medical Support Order (07/2019) Page 2 of 8 II. III. PARENTAL RIGHTS AND RESPONSIBILITIES A. ☐ Plaintiff ☐ Defendant has assigned medical support rights to the state. B. The parties do not seek a parental rights and responsibilities order. C. The parties do not seek a child support order. D. Additional information: ____________________________________________________________________________________ ____________________________________________________________________________________ IV. MEDICAL SUPPORT This is the result of a medical support worksheet which is attached and incorporated as findings in this order. A. The parties are ordered to pay medical support as follows: ☐ Child(ren) are presently covered by state or federally provided health insurance in ☐ Mother’s ☐ Father’s household. This health insurance coverage shall be maintained for the child(ren) for so long as the child(ren) remain eligible for current coverage. ☐ The ☐ Plaintiff ☐ Defendant is ORDERED to provide and maintain private health insurance for the minor child(ren) as long as the cost of health insurance is deemed reasonable. ☐ Private health insurance is currently unavailable to either party. The ______________________ shall pay a cash contribution toward the cost of health coverage as follows: $______________Per ______________ Beginning: ______________________ If private health insurance is currently unavailable to either parent at a reasonable cost but later becomes available to either parent at a reasonable cost, that parent shall be responsible for providing and maintaining health insurance for the minor child(ren). Either parent may request a hearing to determine whether the cost of health insurance is reasonable or file a motion to modify child support with the court if the payment of health insurance premiums by a parent for a child results in a child support guideline/obligation which varies more than ten percent from the amount required to be paid under this Order. B. Current Medical Support Coverage Health Insurance: Policy or Certificate Number: ________________________________________________ Name of Subscriber: _______________________________________________________ Relationship to Child(ren): __________________________________________________ Plan Name: ______________________________________________________________ Plan Address: _____________________________________________________________ Subscriber ID Number: _____________________________________________________ C. Child(ren)'s Out of Pocket Medical Expenses Medical or other health expenses that are unreimbursed by insurance (including but not limited to expenses for eye, dental, mental health, health plan deductible) shall be shared as follows: 1) Obligee is solely responsible for the first $200 annually of the children’s out of pocket health expenses. 2) The parties shall share unreimbursed expenses as follows: Obligor __________% Obligee __________% 3) Additional Provisions: __________________________________________________________________ 400-00802M - Medical Support Order (07/2019) Page 3 of 8 D. Additional Medical Support Provisions 1. If employed, a parent under a medical support order shall notify his/her employer of such obligation, in writing, within 10 days of the date of this order. 2. If self-employed or unemployed, a parent under a medical support order shall notify his/her health care insurer of such obligation in writing within 10 days of the date of this order. 3. A parent is liable for any unreimbursed health care costs of the child(ren) that result from that parent's failure to give notice/obtain insurance as ordered above, which accrues between the date of this order and the date that the order is modified by the Court. 4. If a parent has health insurance through an entity other than his/her employer, that parent shall be responsible for maintaining that insurance and complying with any notice requirements under the policy in effect. Failure to do so will make the parent liable for paying any unreimbursed health care expenses that accrue between the date of this order and the date this order is modified by the Court. 5. If a parent pays a health expense of a child subject to this order and the other parent receives reimbursement from insurance for the expense, the reimbursement shall be sent to the parent who advanced payment, within 30 days of receipt. If the child(ren) also have Medicaid coverage, payment is to be sent to: Office of Health Access, 312 Hurricane Drive, Suite 201, Williston, VT 05495-2806, within 30 days. 6. The parties shall provide each other with copies of bills for health expenses and documentation of insurance determination within 30 days of receipt. The parent who maintains insurance shall also provide the other parent with a health insurance card, claim forms and a list of benefits and restrictions within 10 days of the date of this order. V. ARREARS ON PAST DUE MEDICAL SUPPORT/REPAYMENT PROVISIONS A. Arrears Owed Office of Child Support ☐ Plaintiff ☐ Defendant shall pay the Office for Child Support as follows: $__________ per __________ on a judgment of $__________ as of ____________________ The judgment consists of the following past due amounts: $__________ Other: $__________ B. Arrears Owed to ☐ Plaintiff ☐ Defendant ☐ Plaintiff ☐ Defendant shall pay the other party as follows: $__________ per __________ on a judgment of $__________ as of ____________________ The judgment consists of the following past due amounts: $__________ Other: $__________ 400-00802M - Medical Support Order (07/2019) Page 4 of 8 C. Arrears Owed to Other Agency ☐ Plaintiff ☐ Defendant shall pay to __________________________________ as follows: $__________ per __________ on a judgment of $__________ as of ____________________ The judgment consists of the following past due amounts: $__________ Other: $__________ VII. Method of Payment A. WAGE WITHHOLDING ORDER Any employer of ☐ Plaintiff ☐ Defendant shall deduct the following sum from his/her wages: $__________ per __________ This deducted amount shall be paid directly to: OFFICE OF CHILD SUPPORT PO BOX 1310 WILLISTON, VT 05495 B. DIRECT PAYMENT Based upon ☐ Stipulation of the parties ☐ Evidence presented at hearing ☐ ☐ Plaintiff ☐ Defendant shall make payments directly to the Office for Child Support as follows: ____________________ $__________per __________ This deducted amount shall be paid directly to: OFFICE OF CHILD SUPPORT PO BOX 1310 WILLISTON, VT 05495 ☐ ☐ Plaintiff ☐ Defendant shall make payments directly to the other party as follows: ____________________ $__________ per __________ C. Additional Orders: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 400-00802M - Medical Support Order (07/2019) Page 5 of 8 VII. DURATION OF MEDICAL SUPPORT A. This order shall remain in effect unless and until it is changed or discontinued by further order of the Court or by operation of law. B. Unless otherwise specified, a party's support obligation will continue beyond a child's eighteenth birthday if the child is enrolled in, but has not completed high school, unless otherwise specified. C. If wage withholding is ordered and an arrearage exists when the support obligation terminates, the current monthly payment and any arrearage repayment plan shall not be reduced until the amount is satisfied. The above is stipulated to by the parties: Signature of Plaintiff Approved as to Form Signature of Plaintiff’s Attorney Date Signature of Defendant Date Date Signature of Defendant’s Attorney Date Signature of OCS Representative Date It is so ORDERED Signature of Magistrate or Superior Court Judge Date Printed Name of Magistrate or Superior Court Judge Assistant Judge Date Assistant Judge Date ACCEPTANCE OF SERVICE I have received a copy of this order and I waive all other service. Plaintiff 400-00802M - Medical Support Order (07/2019) Date Defendant Date Page 6 of 8 Additional Conditions of Order & Important Notices A. THIS IS A COURT ORDER All parties are expected to comply with all terms of this order. The address provided to the court shall remain the same for service of future actions and/or orders unless a parent notifies the court of a change. B. A PARTY HAS THE RIGHT TO SEEK MODIFICATION OF THE ORDER BY FILING AN ACTION IN COURT A parent or any other person to whom support has been granted, or any person charged with support, may file a motion for a modification of a child support order under 15 V.S.A. § 660. A modification may be granted upon a real, substantial, and unanticipated change of circumstances, including loss of employment or a considerable reduction or increase in salary or wages. A party is responsible for any required payments set forth in an order unless the order is vacated or modified by a court. Thus, any subsequent agreement between the parties that differs from the order is not legally binding, and the party is still legally required to pay the amount ordered by the court. (15 V.S.A.§ 663 (e)). If a child turns 18 and has completed secondary school, and a parent wants to have support changed, s/he must file a motion to modify child support with the court. C. RIGHT TO SEEK ENFORCEMENT OF THE ORDER 1. A party may place liens on real or personal property. 2. A party may request the court to: » place assets in escrow. » grant a civil penalty when noncompliance of the support is willful. » order wage withholding if the support amount is at least 7 days delinquent. » find the Obligor in Contempt if there is willful noncompliance with this order. » impose surcharges on past due child support. IN ADDITION TO THE REMEDIES LISTED ABOVE: A party has the right to request assistance from the Vermont Office of Child Support in the effort to enforce this order. If the Office of Child Support is or becomes involved in this case, based either on a current or future request for their services, or otherwise, the Office is not limited to but may take the following steps when appropriate: 1. Use any lawful collection remedies to collect any outstanding balance from the Party, regardless of any repayment plan on any unpaid debts. 2. Certify all qualifying child support debts to the Vermont Tax Department and/or the Federal Treasury Offset Program for the purpose of intercepting tax returns and/or other payments (i.e., vendor payments, passport denial, etc.) 3. Report a Party's account balance to consumer credit reporting agencies and/or request a copy of the report. 4. Administratively issue a wage withholding order for current support and/or arrearages in excess of 1/12 of the annual support obligation. 5. Freeze bank accounts and take the proceeds to satisfy past due support. 6. Administratively suspend any and all licenses owned by the Party. This may include, but is not limited to, professional, hunting, fishing, or motor vehicle driver's licenses. 400-00802M - Medical Support Order (07/2019) Page 7 of 8 HEALTH INSURANCE AVAILABILITY & COST WORKSHEET 1. Private health insurance is available to: ☐ Plaintiff ☐ Defendant ☐ Neither Gross monthly income is 5% gross monthly income is Total monthly family health insurance cost to employee Total monthly two person cost to employee Total monthly single person coverage to employee $ $ $ $ $ Plaintiff $ $ $ $ $ Defendant 2. Private health insurance is deemed reasonable for: ☐ Plaintiff ☐ Defendant because: ☐ The cost of adding the child(ren) to an existing health insurance policy is 5% or less of a parent's gross income as calculated above for ☐ Plaintiff ☐ Defendant ☐ The cost of obtaining coverage for the child(ren) is 5% or less of a parent's gross income as calculated above for ☐ Plaintiff ☐ Defendant ☐ the above referenced cost of health insurance is 5% or more of ☐ Plaintiff's ☐ Defendant's gross income and the court has considered the factors of 15 V.S.A. § 659. Additional findings: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 3. Although the cost of health insurance is 5% or less of a parent's gross income, the ☐ Plaintiff ☐ Defendant is not ordered to provide health insurance for the following reasons: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 400-00802M - Medical Support Order (07/2019) Page 8 of 8