Free - Ohio


File Size: 10.3 kB
Pages: 1
Date: January 31, 2006
File Format: PDF
State: Ohio
Category: Court Forms - Local
Author: boylejl
Word Count: 40 Words, 316 Characters
Page Size: Letter (8 1/2" x 11")
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http://www.butlercountyohio.org/drcourt/PDFs/AndyNewForms/2000C33%20explanation%20of%20medical%20bills.pdf

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C33 Eff. 10/31/97

PAGE _____ OF _____.

EXPLANATION OF MEDICAL BILLS
NAME OF CHILD DATE OF TREATMENT (CHRONOLOGICAL ORDER) NAME OF SERVICE PROVIDER (DOCTOR, DENTIST, HOSPITAL) TOTAL BILL INSURANCE PAID AMOUNT OF BILL UNPAID AMOUNT DUE FROM EX-SPOUSE

TOTALS PAGE TOTAL ____________________________________________