OMB 0970-0222 & 1210-0113
These documents serve 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 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.
- PDF OMB 0970-0222 - National Medical Support Notice - Part A.pdf (305.97 KB)
- PDF OMB 1210-0113 - National Medical Support Notice - Part B.pdf (273.11 KB)