Allegan County, MI · Allegan County
Request for Health-Care Expense Payment
A parent or other requesting party uses this form to ask an obligor to pay their required share of a child’s health-care expenses.
At a glance
- Issued by
- City of Allegan County · Allegan County, Allegan County, Michigan
- Notarization
- Not required: file this form without a notary.
- Official source
- courts.michigan.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form requests payment from an obligor for a minor child’s health-care expenses when a court order requires the other party to pay a portion. The requesting party lists each expense, provider, service date, insurance payment, balance, and amount owed by the obligor. Attach copies of bills and insurance notifications; the instructions also describe requirements for presenting bills to the friend of the court.
Who needs it
A person seeking payment from an obligor for a minor child’s health-care expenses may use this form when the court order requires the obligor to contribute.
How to submit it
Send the completed form and copies of all bills and insurance notifications to the obligor. The instructions say to present supporting bills to the friend of the court if seeking enforcement.
About notarization
This form is signed and dated without a notary; it requires copies of bills and insurance notifications, but identifies no sworn or notarized attachment.
How to submit this form
- 1
Download the Form
Download the Request for Health-Care Expense Payment form.
- 2
Complete the Expense Details
List each health-care expense on page 2, including the child, provider, service date, costs, insurance payment, balance, and amount owed.
- 3
Gather Attachments
Attach copies of all bills and insurance notifications, and keep a copy of the form and attachments.
- 4
Send the Request
Send the completed form and attachments to the obligor; present supporting bills to the friend of the court if seeking enforcement.
Frequently asked questions
- What is the Request for Health-Care Expense Payment?
- It is a form for asking an obligor to pay their share of a minor child’s health-care expenses. It includes fields for providers, services, insurance payments, balances, and amounts owed.
- What documents should I attach?
- Attach copies of all bills and insurance notifications. Keep a copy of the form and attachments, and retain supporting bills and receipts in case enforcement is necessary.
- Do I need a notary for the Request for Health-Care Expense Payment?
- No. This form is signed and dated without a notary. It requires copies of bills and insurance notifications, but identifies no sworn or notarized attachment.
- How do I submit the Request for Health-Care Expense Payment?
- Send the completed form with copies of bills and insurance notifications to the obligor. If seeking enforcement, present supporting bills to the friend of the court.