Eaton County, MI · Eaton County
Request for Health Care Expense Reimbursement
A requesting party uses this form to seek reimbursement for a minor child’s health care expenses not covered by insurance.
At a glance
- Issued by
- City of Eaton County · Eaton County, Eaton County, Michigan
- Notarization
- Not required: file this form without a notary.
- Official source
- eatoncounty.org
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form records a minor child’s health care expenses and the amount remaining after insurance payment. The requesting party provides the child’s name, medical provider, service date and type, costs, and contact information for both parties. It states that payment is requested within 28 days of the mailing date and that an unpaid request will be sent to the Friend of the Court for enforcement.
Who needs it
A party seeking payment for a minor child’s health care expenses not covered by insurance uses this form.
How to submit it
Mail a copy of the request to the other party at their last known address. If payment is not received within 28 days from the mailing date, the form says it will be sent to the Friend of the Court for enforcement.
About notarization
No notary is required; the requesting party declares the information true, confirms mailing a copy to the other party, and signs and dates the form.
How to submit this form
- 1
Download the Form
Download the Request for Health Care Expense Reimbursement.
- 2
Complete the Expense Details
Enter the child’s name, medical provider, service date and type, medical cost, insurance payment, and remaining balance.
- 3
Add Party Information
Provide the requesting party’s and other party’s names, addresses, and phone numbers.
- 4
Sign, Date, and Mail a Copy
Sign and date the form, then mail a copy to the other party at their last known address.
Frequently asked questions
- What is the Request for Health Care Expense Reimbursement?
- It records a minor child’s health care expenses, insurance payments, and remaining balance, and requests payment from the other party.
- Do I need a notary for the health care reimbursement request?
- No. The requesting party declares the information true and signs and dates the form; it also states that a copy was mailed to the other party.
- How do I submit the reimbursement request?
- Mail a copy to the other party at their last known address. The form says an unpaid request will be sent to the Friend of the Court for enforcement after 28 days from the mailing date.