Motion To Modify Child Support Forms Package (Page 12 of 36) in pdf

Health Expenses Not Covered by Insurance

8. Medical, Dental, Vision, or Psychological Expenses not Covered by Insurance

You must check one and only one of the following four boxes.

The person receiving support will pay all reasonable and necessary medical and dental expenses of the

children not covered by insurance and the person paying support will reimburse the person receiving support for

_______ percent of all such expenses that are actually paid by the person receiving support and are in excess of

$250 per year per child. This does not include the uninsured extraordinary costs set forth in paragraph 9 below.

No reimbursement of uncovered medical and dental expenses of the children will be allowed unless the person

receiving support submits proof of such expenses to the person paying support in writing within 120 days of the

date said expenses were incurred. Except for good cause, no legal proceedings seeking reimbursement will be

allowed unless instituted within 360 days of the date said expenses were incurred.

Medical and dental expenses are defined by §213(d)(1)(A) of the Internal Revenue Code.

(RSMo. §454.633.3 provides that if you have checked this first box in Paragraph 8 and you have not

provided a percentage, then each parent will be responsible for one-half of all reasonable and necessary

medical or dental expenses of the children not covered by insurance except as set forth in Paragraph 9 below.)

The person paying support does not have the financial resources to contribute to the payment of medical or

dental expenses of the children not covered by insurance. The person receiving support will be responsible for

all reasonable and necessary medical or dental expenses of the children not covered by insurance. This does not

apply to the medical costs listed in Paragraph 9 below. RSMo. §454.603.5(2)

All reasonable and necessary medical or dental expenses of the children are covered by insurance. RSMo.

§454.603.5(1)

The person receiving support has not substantially complied with the terms of the health benefit coverage.

The person receiving support will be responsible for all reasonable and necessary medical or dental expenses of

the children not covered by insurance. This does not apply to the medical costs listed in Paragraph 9 below.

RSMo. §454.603.5(3)

9. Payment of Uninsured Extraordinary Medical Costs

Extraordinary medical costs are predictable and recurring, such as expenses for dental treatment,

orthodontic treatment, asthma treatment and physical therapy. These expenses MAY be included in the Form

14 calculation. (If no extraordinary medical costs are to be included on Form 14, you may leave this

information blank.)

Uncovered Extraordinary Medical Costs to be Paid by

Amount of Expense

Father INCLUDED on Form 14

$___________ per month

_______________________________________________________

Form 14

$___________ per month

_______________________________________________________

$___________ per month

_______________________________________________________

The total cost of these uncovered extraordinary medical costs of the children is $___________ per

month. This amount HAS been included in the child support calculation pursuant to Form 14. (You must

include this amount on Form 14 - Line 6d)

Uncovered Extraordinary Medical Costs to be Paid by

Amount of Expense

Mother INCLUDED on Form 14

$___________ per month

_______________________________________________________

$___________ per month

_______________________________________________________

$___________ per month

_______________________________________________________

The total cost of these uncovered extraordinary medical costs of the children is $___________ per

month. This amount HAS been included in the child support calculation pursuant to Form 14. (You must

include this amount on Form 14 - Line 6d)

Parenting Plan Part B - Support – Page 4

Form CAFC501-08/29/2009

This form is available for free at

Motion To Modify Child Support Forms Package Page 12

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