Other Source Health Insurance Information

- Date: Office of the Attorney General MEDICAL SUPPORT UNIT P.O. BOX 1328 AUSTIN, TEXAS 78767-1328 Toll-Free (800) FAX (855) 329-6676 Obligee/Obligor Name: Obligee/Obligor SSN: Case #: Employer Address: Cause #: OTHER SOURCE HEALTH INSURANCE INFORMATION Please provide this agency with the information requested below regarding your employee (obligor) within 20 business days after the date of the notice, or sooner, if reasonable. PLEASE RETURN THIS FORM TO THE ADDRESS LISTED ABOVE ***Please enclose copies of: Health insurance policy; Schedule of benefits; Insurance membership cards; Claim forms*** Child Name DOB SSN Enroll ment Date Complete the following for all children that have health insurance from another source If insurance details are unknown, provide the employee222s address and phone number: Mark the item(s) below (with a 223X224) to indicate the type of coverage provided: Medical Dental Vision Prescription Drug Mental Health Other (specify): Name of Insurance Carrier: Telephone Number: - - Group Number: Policy Number: Address: City: State: ZIP Code: Please PRINT legibly within the boxes, do not cross the lines, use black ink! Do you currently withhold child support related wages from this employee? Yes No Employer Last Name First Name Contact Info Date form completed Position/Title / / Telephone Number Email Address - - Date valid insurance confirmed FOR OAG VENDOR ONLY November 201 American LegalNet, Inc. www.FormsWorkFlow.com