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
Plaintiff Defendant
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
