New York Child Support Order Form

The Medical Child Support Order is a form that is used for ensuring that minor children involved in a divorce case remain in the parent’s health insurance policies.

Extracted Text for Proper Search

At a term of the Supreme Court of the 
State of New York, held in and for the 
 County of        
 at       , New York 
 on        
 
 
 PRESENT: Hon.        
Justice/Referee 
--------------------------------------------------------------- 
   
   
   
   
   
   
   
   
   Index No.:         
Plaintiff, 
-against- QUALIFIED MEDICAL 
CHILD SUPPORT ORDER 
 
   
   
   
   
   
   
   
   
Defendant. 
--------------------------------------------------------------- 
 
NOTICE:  YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY, AFTER A COURT 
HEARING, RESULT IN YOUR COMMITMENT TO JAIL FOR A TERM NOT TO EXCEED 
SIX MONTHS, FOR CONTEMPT OF COURT. 
 
 Pursuant to DRL §240(1).  This Qualified Medical Child Support Order (QMCSO) orders  
 and directs that the unemancipated dependents named herein: 
Name: Date of Birth: Soc. Sec.#: Mailing Address: 
 
                            
 
                            
 
are entitled to be enrolled in and receive the benefits for which the legally responsible 
relative named herein is eligible, under the group health plan named herein in accordance 
with Section 609 of the Federal Employee Retirement Income Security Act. 
 
 The Participant (legally responsible relative) is: 
Name: Soc.  Sec.#: Mailing Address: 
 
                     
 
       
 
 The Dependents’ Custodial Parent or Legal Guardian who is to be provided with any  
 identification cards and benefit claim forms on behalf of dependents: 
Name: Soc. Sec.# :Mailing Address: 
 
                     
 
 
 
 
(Form UD-8b - Rev. 5/99)

The group health plan subject to this order is: 
Name: Address: Identification No.: 
 
                     
 
 The administrator of said plan is: 
Name: Address: 
 
              
 
 The type of coverage provided is: 
 
       
 
 ORDERED that coverage shall include all plans covering the health, medical, dental,  
pharmaceutical and optical needs of the aforementioned Dependents named above for 
which the Participant is eligible. 
 
 ORDERED that said coverage shall be effective as of (give date)        
and shall continue as available until the respective emancipation of the aforementioned 
dependents. 
 
ENTER: 
 
 DATED:           
JSC/Referee 
 
TO: [Health Insurer] 
 
 NOTICE:  Pursuant to Section 5241(g)(4) of the Civil Practice Laws and Rules, if an 
employer, organization or group health plan fails to enroll eligible dependents or to deduct from 
the debtor's income the debtor's share of the premium, such employer, organization or group 
health plan administrator shall be jointly and severally liable for all medical expenses incurred on 
behalf of the debtor's dependents named in the execution while such dependents are not so 
enrolled to the extent of the insurance benefits that should have been provided under such 
execution. 
 
 The group health plan is not required to provide any type or form of benefit or option not 
otherwise provided under the group health plan except to the extent necessary to meet the 
requirements of a law relating to medical child support described in section one thousand three 
hundred and ninety six g-1 of title forty-two of the United States Code. 
 
 
 
 
 
 
 
(Form UD-8b - Rev. 5/99)