Statement Of Health Care Expenses {DR-353}

STATEMENT OF HEALTH CARE EXPENSES Name of Parent Filling Out Statement Parent A Parent B In the chart below, list each health care expense, beginning with the oldest one. If you do not know the answer to a question, write "unknown" in that box. Attach: (1) a copy of each health care provider's bill, (2) proof of any amount you paid the provider, (3) a copy of each "Explanation of Benefits" (EOB) from an insurance company, and (4) a copy of each request for payment you sent the other parent. At the bottom of each attached document, write and circle the number on the chart that corresponds to that item. Attach the documents in order by that number. a Date of health care service b Name of health care provider c Name of Patient d Amount charged by provider (attach copy of bill) e Amount you paid provider (attach proof of payment) f g h Amount not Amount paid by paid by any Amount other insurance insurance parent owes companies company and you (attach EOBs) still owed on bill FOR COURT USE ONLY Court Findings i Amount owed j Owed to 1 2 3 4 5 6 7 Total American LegalNet, Inc. www.FormsWorkFlow.com DR-353 STATEMENT OF HEALTH CARE EXPENSES (3/16) Civil Rule 90.3(d)(2) & (f)(5)