Free ORDER TO MAINTAIN HEALTH INSURANCE FOR MINOR CHILD(REN) - Connecticut

ORDER TO MAINTAIN HEALTH INSURANCE FOR MINOR CHILD(REN)
JD-FM-125 Rev. 5-06 C.G.S. 46b-84(e) NAME AND ADDRESS OF COURT NAME OF PLAINTIFF TYPE OF CASE

STATE OF CONNECTICUT SUPERIOR COURT
To be prepared by counsel or parties and submitted to the court for verification and certification. COPY: Custodial Parent or Custodian
DOCKET NO. NAME OF DEFENDANT DATE OF ORDER

DISTRIBUTION: ORIGINAL: Court File

www.jud.ct.gov

Dissolution
CASE STATUS

Annulment Final Judgment

Legal Separation PostJudgment

Support Action

Custody Action

CUSTODIAL PARENT OR CUSTODIAN (If joint custody, parent who maintains primary
place of residence for child(ren)

Pendente Lite

1. The above-named defendant is ordered to maintain the following health insurance coverage as available in plaintiff the manner prescribed below for the benefit of the below-named child(ren): TYPE OF COVERAGE AVAILABLE THROUGH
MEDICAL OTHER (Specify) HIS/HER EMPLOYMENT NAME HIS/HER UNION DATE OF BIRTH OTHER AVAILABLE GROUP PLAN NAME PRIVATELY DATE OF BIRTH DENTAL HOSPITALIZATION

CHILDREN TO BE COVERED

The above-mentioned order of health insurance is subject to the following conditions, if any:

2. The above-mentioned health insurance coverage is to be effective on (date): 3. Said plaintiff defendant is ordered to provide certification or verification of such insurance to the: Dept. of Social Services Custodial Parent Custodian

Support Enf. Office on or before (date):

Fam. Services Office

4. It is further ordered that: A. the signature of the custodial parent or custodian of the insured minor child(ren) shall constitute a valid authorization to the insurer for purposes of processing an insurance reimbursement payment to the provider of the medical services or to the custodial parent or custodian; B. neither parent shall prevent or interfere with the timely processing of any insurance reimbursement claim; and C. if the parent receiving an insurance reimbursement payment is not the parent who is paying the bill for the services of the medical provider, the parent receiving such insurance reimbursement payment shall promptly pay to the parent or custodian paying such bill any insurance reimbursement for such services.
BY THE COURT (Print or type name of Judge/Family Support Magistrate) SIGNED (Judge, Family Support Magistrate, Clerk, Asst. Clerk) DATE SIGNED

I hereby certify that the above order is a true copy of the order requiring maintenance of health insurance for the above-named child(ren). In testimony whereof, I have hereunto set my hand and affixed the seal of said court at the CERTIFICATION above location on:
DATE SIGNED (Clerk, Asst. Clerk)

SEE IMPORTANT NOTICE TO CUSTODIAL PARENT OR CUSTODIAN ON PAGE 2

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NOTICE TO THE CUSTODIAL PARENT OR GUARDIAN Pursuant to C.G.S. § 46b-84(e), the custodial parent or custodian is responsible for providing the insurer with a certified copy of the order requiring maintenance of health insurance for a minor child as well as any subsequent modification of the order. HEALTH INSURANCE PROVIDER INFORMATION (Do not complete until after the court has certified the order on the reverse side.) The information provided below is not being certified by the court and is provided for informational purposes only.
HEALTH INSURANCE PROVIDER GROUP NUMBER MEMBERSHIP NO.

JD-FM-125 (page 2) Rev. 5-06

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