Form 4-6 - Temporary Order Of Support (And Referral To Support Magistrate) (Page 5 of 9) in pdf

Form 4-6 - Temporary Order Of Support (And Referral To Support Magistrate) Page 5

Form 4-6 Page 5

The father is the Q custodial Q non-custodial parent, whose pro rata share of the cost or premiums to

obtain or maintain such health insurance coverage is

;

And the Court further finds that [check applicable box]:

G Each parent shall pay the cost or premiums in the same proportion as each of their incomes are to

the combined parental income as cited above;

G Upon consideration of the following factors [specify]:

pro-rating the payment would be unjust or inappropriate for the following reasons [specify]:

and, therefore, the payments shall be allocated as follows [specify]:

; and it is further

G [Where the child(ren) are recipients of managed care coverage under the New York State Medical

Assistance Program] ORDERED that

, the non-custodial parent herein, shall pay the

amount of $

per

toward to the managed care premium under the New York State

Medical Assistance Program;

GWhere the child(ren) are recipients of fee-for-service coverage under the New York State Medical

Assistance Program] ORDERED that

, the non-custodial parent herein, shall

pay up to an annual maximum of $

for the current calendar year to the New York State

Medical Assistance Program upon written notice that the program has paid health care expenses on

behalf of the child(ren) for costs incurred during the current calendar year.

G [Where the child(ren) are recipients of fee-for-service coverage under the New York State

Medical Assistance Program] ORDERED that

, the non-custodial parent herein,

pay as part of the cash medical support obligation up to an annual maximum of $

for the calendar year commencing January 1,

and for every year thereafter to the New York

State Medical Assistance Program upon written notice that the Medicaid program has paid health care

expenses on behalf of the child(ren).

G ORDERED that

, the non-custodial parent herein, shall pay the

amount of $

, representing his/her share of premiums and/or costs incurred by the New

York State Medical Assistance Program for the period of time from

to the date

of this order, which amount shall be support arrears/past due support;

G ORDERED that in the event that the child(ren) cease(s) to be enrolled in the New York State

Medical Assistance Program, the non-custodial parent’s obligation to pay his/her share of managed

care coverage premiums and/or fee-for-service reimbursement shall terminate as of the date the

child(ren) is/are no longer enrolled in Medicaid;

Form 4-6 - Temporary Order Of Support (And Referral To Support Magistrate) Page 5

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