Annual Ordinary Medical Expense Tracking Log printable pdf download

Annual Ordinary Medical Expense Tracking Log

If you are a custodial parent, and your order provides for annual ordinary medical, you must provide written proof each

year that you have paid out of pocket expenses that are equal to the annual ordinary medical expense amount

established in your order before requesting payment or enforcement of medical expenses.

Out of Pocket expenses include co-payments, deductibles, prescriptions, and other non-routine uninsured health care

related costs for children. Routine medical, such as first-aid supplies, cough syrup, and vitamins cannot be submitted,

because they are a part of the normal day to day expenses of raising a child.

Under the Michigan Child Support Formula, out-of-pocket expenses do not include health care premiums, because they

are factored into the base support amount. If there is a premium that has not been addressed in the base support

calculation, either party can request a support review.

ATTACH COPIES OF ALL PROOF OF PAYMENTS, WHICH MUST SHOW THE FOLLOWING INFORMATION:

Date of Service, Patient Name, Type of Service, Cost of Service

Date of

Name of Physician or

Date of

Amount paid out

Name of Child

Nature of Service

Service

Provider

Receipt

of pocket

Total: _______________*

*Your total must be equal to or greater than the Annual Ordinary Medial Amount specified in your order.

Jackson County Friend of the Court

01/02/13

Annual Ordinary Medical Expense Tracking Log

Annual Ordinary Medical Expense Tracking Log