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National Medical Support Notice Form & Instructions

OMB 0970-0222

Published: March 25, 2014

This document serves as legal notice that the employee identified on this National Medical Support Notice is obligated by a court or administrative child support order to provide health care coverage for the child(ren) identified on this Notice. This National Medical Support Notice replaces any Medical Support Notice that the Issuing Agency has previously served with respect to the employee and the children listed on this Notice.

The document consists of Part A - Notice to Withhold for Health Care Coverage for the employer to withhold any employee contributions required by the group health plan(s) in which the child(ren) is/are enrolled; and Part B - Medical Support Notice to the Plan Administrator, which must be forwarded to the Administrator of each group health plan identified by the employer to enroll the eligible child(ren), or completed by the employer, if the employer serves as the health Plan Administrator.

*Note - although Part B expired 3/31/16, it is still valid. Please continue to use this form until the new one is issued.

 

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Last Reviewed: July 28, 2016

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