Fill and Sign the Original Obligor Form

INSTRUCTIONS FOR REQUESTING PARTY: The following is important information should you later seek to obtain the friend of the court's help to enforce payment of health-care expenses (medical, dental, and other health-care expenses). 1. Your court order must require the other party to pay a portion of health-care expenses. 2. The expense must exceed any amounts your child support order requires as a prerequisite for enforcement. 3. You must submit your request for payment to the other party within 28 days of either the date the insurance provider has paid on the expenses or the date the insurance provider denies payment. 4. If you and the other party reach an agreement concerning the expenses, the agreement must be in writing, and the agreement must list the expenses to be paid, state the total amount to be paid, and provide a schedule for payment. Both parties must sign the agreement. 5. The bills must be presented to the friend of the court on or before the following: one year after the expense was incurred, or six months after the insurer's final denial of coverage for the expense (as long as all measures necessary to submit the claim to insurance were completed within two months after the expense was incurred), or six months after a default in a repayment agreement as set forth above. You will need to fill out a second form to request enforcement. 6. In the event it is necessary for the friend of the court to enforce payment of the expenses, you must have supporting bills and receipts for the expenses you list. You will be responsible for establishing the expenses and their necessity. Please bring your documentation to all court hearings where medical expenses may be discussed. 7. Attach a copy of all bills and insurance notifications to this form. 8.You must keep a copy of this form and all attachments for the friend of the court to use in the event enforcement action is necessary. TO: Complete expenses incurred on the other side of this form. Telephone no. Friend of court address PlaintiffDefendant v Obligor's name and address REQUEST FOR HEALTH-CARE EXPENSE PAYMENT MCL 552.511a FOC 13 (3/12) REQUEST FOR HEALTH-CARE EXPENSE PAYMENT Approved, SCAO STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT COUNTY Original - Obligor 1st copy - Requesting party 2nd copy - For court as needed Name of Child Receiving Service Name of Medical ProviderDate of ServiceType of ServiceTotal Medical CostAmt. Paid by InsuranceAmt. Owed by Obligor Balance Due* Obligor's % The following expenses have been incurred for the health care of a minor child for whom you are obligated to provide health-care support. *Balance due means balance owed after payment by insurance and any adjustments to the total medical cost. Signature Plaintiff v Defendant CASE NO. Date