Form 4-7 - Order Of Support (Page 7 of 9) in pdf

Form 4-7

Page 7

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;

; and it is further

ORDERED that the legally responsible relative immediately notify the [check applicable

box]: G other party (non-IV-D cases) G Support Collection Unit (IV-D cases) of any change in health

insurance benefits, including any termination of benefits, change in the health insurance benefit carrier

or premium, or extent and availability of existing or new benefits; and it is further

ORDERED, that [specify name]:

shall execute and deliver to

[specify name]:

any forms, documents, or instruments to assure timely

payment of any health insurance claim for the child(ren); and it is further

ORDERED that upon a finding that the above-named legally-responsible relative(s) willfully

failed to obtain health insurance benefits in violation of [check applicable box(es)]: G this order

G the medical execution G the qualified medical child support order, such relative(s) will be

presumptively liable for all health care expenses incurred on behalf of the above-named defendant(s)

from the first date such dependent(s) Q was Q were eligible to be enrolled to receive health insurance

benefits after the issuance of such order or execution directing the acquisition of such coverage; and it is

further

ORDERED that [specify]:

the legally-responsible

relative(s) herein, shall pay (his)(her) pro rata share of future reasonable health expenses of the

child(ren) not covered by insurance by [check applicable box]: G direct payments to the health care

provider G other [specify]:

; and it is further

ORDERED that, if health insurance benefits for the above-named child(ren) not available at

the present time become available in the future to the legally-responsible relative(s), such relative(s)

shall enroll the dependent(s) who are eligible for such benefits immediately and without regard to

seasonal enrollment restrictions and shall maintain such benefits so long as they remain available; and it

is further

[Check applicable box(es):

G [Where the Court has made a finding that health insurance is not available] ORDERED that

an execution for medical support enforcement shall not be issued by the support collection unit unless a

subsequent determination is made by the Court that such health insurance benefits are available; and it

is further

G ORDERED that

, the non-custodial parent

as Q his Q her proportionate share of reasonable child care

herein, pay the sum of $

expenses, to be paid as follows:

; and it is further

G ORDERED that

, the non-custodial parent herein, pay the sum of

as educational expenses by G direct payment to the educational provider

G other [specify]:

Form 4-7 - Order Of Support Page 7

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