Uniform Domest Relations Form 29/Uniform Juvenile Form 8 (Explanation of Health Care Bills)

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Supreme Court of Ohio Uniform Domestic Relations Form 29 Uniform Juvenile Form 8 Explanation of Health Care Bills Approved under Ohio Civil Rule 84 and Ohio Juvenile Rule 46 Amended: Page 1 of 1 Name of Child: Case No. Instructions: This form is used when you are claiming the other party has not paid health care bills. Use a separate form for each child. A Motion for Contempt and Affidavit (Uniform Domestic Relations Form 24/Uniform Juvenile Form 3) and a Show Cause Order and Notice to the Clerk (Uniform Domestic Relations Form 25/Uniform Juvenile Form 4) must be filed. You must bring copies of health care bills, Explanation of Benefits forms, and proof of payment to the hearing. Be prepared to indicate the amount owed to you, service providers, collection agencies, or other entities. If more space is needed, add additional pages. The Court may require additional forms to accompany this document. You must check the requirements of the county in which you file. EXPLANATION OF HEALTH CARE BILLS Date of Treatment Name of Service Provider (e.g., Doctor, Dentist, Therapist, Hospital) & Services Provided Total Bill Date Bill Sent to Other Party Amount Insurance Paid Amount You Paid Amount Paid by Other Party Amount of Unpaid Bill Amount Due from Other Party Total Amount of Claim $ Your Signature Date 1 September 21, 2020