Approved,  SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT
COUNTY

Friend  of  court  address

Plaintiff

REQUEST  FOR  HEALTH-CARE
EXPENSE  PAYMENT

v

Defendant

Original - Obligor
1st  copy  -  Requesting  party
2nd copy - For court as needed

CASE NO.

Telephone    no.

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.

Obligor's name and address

TO:

Complete expenses incurred on the other side of this form.

FOC 13   (3/12)   REQUEST FOR HEALTH-CARE EXPENSE PAYMENT

MCL  552.511a

Signature

Date

*Balance due means balance owed after payment by insurance and any adjustments to the total medical cost.

Obligor
by
Amt. Owed

%

Obligor's

Due*
Balance

Insurance
by
Amt. Paid

Cost
Medical
Total

Service
Type of

Service
Date of

Medical Provider
Name of

Receiving Service
Name of Child

The following expenses have been incurred for the health care of a minor child for whom you are obligated to provide health-care support.

CASE NO.

Defendant

v

Plaintiff