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MEDICAL SUPPORT ORDER (Vermont Judiciary)

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400-00802M - Medical Support Order (07/2019) Page 1 of 8
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Plaintiff Name
DOB
v.
Defendant Name
DOB
Other Party Name:
Other Party Name:
MEDICAL SUPPORT ORDER
PLAINTIFF'S EMPLOYER or Source of
Funds
Name
Mailing Address
City State
Zip Code
Phone Number
Phone
Number
Social Security Number
Email Address
DEFENDANT
DEFENDANT'S EMPLOYER or Source of
Funds
First-Name Last Name
Name
Mailing Address
Mailing Address
City State Zip Code
,
City State Z
ip Code
Phone Number
Phone
Number
Social Security Number
Email Address
CHILDREN
WHO ARE
SUBJECT
OF THIS ORDER
First Name Last Name
Date of Birth
Grade
Social Security Number
Addison Unit
400-00802M - Medical Support Order (07/2019) Page 2 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)
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 o
n:
☐ 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which was filed with the Vermont Department of Health and has not been rescinded or challenged,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)___________________________________________________________________________
certified mail restricted delivery on:
400-00802M - Medical Support Order (07/2019) Page 3 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 4 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 5 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 6 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
Date
Signature of Defendant
Date
Approved as to Form
Signature of Plaintiff’s Attorney
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
Date
Defendant
Date
400-00802M - Medical Support Order (07/2019) Page 7 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 8 of 8
HEALTH INSURANCE AVAILABILITY & COST WORKSHEET
1. Private health insurance is available to: ☐ Plaintiff ☐ Defendant ☐ Neither
Plaintiff
Defendant
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
$
$
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:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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Completed 30 July 2020

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