Full Text
TALLY SHEET FOR ORDINARY & ADDITIONAL ORDINARY MEDICAL EXPENSES FOR CALENDAR YEAR (2021 MCSF) Case No. Name of Parent seeking reimbursement Parent phone Parent Number of children in this case multiplied by the per child annual ordinary medical expense of $454.00 in the support order = (Formula per child rate effective date 1/1/2021) Example: 3 children x $454.00 (ordered amount per child per year) = $1,362.00 Complete the following lines and maintain a running total for qualified Ordinary Medical Expenses for this calendar year. Arrange entries by date (earliest expense first). When the running total meets or exceeds the Annual Ordinary Medical Expenditure Total, you may request the percentage reimbursement from the other party for future qualified medical expenses (Additional Ordinary Medical Expenses) either voluntarily between the parties or by using the Health Care Expense Policy/procedure of the 46th Circuit Court. The Policy and forms FOC13 (Request for Health-Care Expense Payment) and FOC 13a (Complaint and Notice for Health Care Expense Payment) are available from Friend of the Court. NOTE: The FOC 13 must be submitted to the other parent within 28 days of the date the insurance provider has paid on the expenses or the date the insurance provider denied payment. Copies of supporting documents for all entries below must be included with this sheet. Child Receiving Service Name of Medical Provider Date of Service Type of Service Medical Cost Amount Paid by Insurance Uninsured Medical Cost Running Total of Uninsured Costs ---PAGE BREAK--- Child Receiving Service Name of medical provider Date of service Type of Service Medical Cost Amount Paid by Insurance Uninsured Medical Cost Running Total of Uninsured Costs ---PAGE BREAK---