OMB 0970-0222 & 1210-0113
National Medical Support Notice Form
These documents serve as legal notice that the employee identified on this National Medical Support Notice (NMSN) is obligated by a court or administrative child support order to provide health care coverage for the child(ren) identified on this notice. This NMSN form 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 Notice has two parts:
- Part A - Notice to Withhold for Health Care Coverage (OMB 0970-0222) (PDF) 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 (OMB 1210-0113) (PDF), 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.
View the Medical Support — FAQs for answers to employers’ common questions.
Supplemental Instructions for Employers, Employer Partners, and Child Support Agencies
The Supplemental Instructions (PDF) provide guidance for completing the OMB-approved Part A NMSN form. The instructions describe the contents of each field and indicate whether each field is mandatory or optional.
Part A Sample Form
This NMSN Part A sample form (PDF) has numbered fields that correspond to the numbers in the instructions.
State Medical Support matrix
This State Medical Support matrix provides state-specific information about medical support contact information, priority for withholding, state statute on medical support, and the state's definition of reasonable cost for medical support.