Health Insurance Disclosure Affidavit HIDA {DR-19}

<document>IN THE COMMON PLEAS COURT OF MONTGOMERY COUNTY, OHIO DIVISION OF DOMESTIC RELATIONSCase No.:Plaintiff/Petitioner(1)SETS No.:V.:JUDGE:Defendant/Petitioner(2)/RespondentMAGISTRATEHealth Insurance Disclosure Affidavit (HIDA) of INSTRUCTIONS: This affidavit must be filed according to local rules of court. You are required to disclose all requested information. You may need to consult your employer to complete this form. There is a continuing legal duty to update the information contained in this form. If more space is needed, attached additional page(s). Please type or print legibly.Children Subject to Support OrderHusband / Father / OtherNameDOBSS#DOBSS#Street Residence AddressNameSS#DOBWife / Mother / OtherNameDOBSS#SS#DOBStreet Residence AddressNameSS#DOBForm # DR-19 (Revised 4/00)HIDA Page 1 of 52001 © American LegalNet, Inc.You are to disclose all requested information in the column for you and in the column for the other party. Part IPart IIHusband / Father / OtherWife / Mother / OtherNameNameEmployerEmployerEmployer AddressEmployer AddressEmployer PhoneEmployer PhoneIs Medicaid coverage available? Yes NoIs Medicaid coverage available? Yes NoIs Medicare coverage available? Yes NoIs Medicaid coverage available? Yes NoIs family health insurance available Yes NoIs family health insurance available Yes No either through the employer oreither through the employer or another group or organization?another group or organization?If not, is private insurance available? Yes NoIf not, is private insurance available? Yes NoIs coverage presently in effect? Yes NoIs coverage presently in effect? Yes No Who is presently covered?Who is presently covered?NameRelationshipNameRelationshipInsurer / Plan NamePhonePhoneInsurer / Plan NameAddressAddressPolicy / Group #Policy / Group #Other Policy ? Group # (if another policy is available)Other Policy? Group? (If another policy is available)HIDA Page 2 of 52001 © American LegalNet, Inc.You are to disclose all requested information in the column for you and in the column for the other party.Part I (Continued)Part II (Continued) Husband / Father / OtherWife / Mother / OtherIs there a cost for coverage? Yes NoIs there a cost for coverage? Yes NoSpecial Instruction -The court requires both theSpecial Instruction -The court requires both the family cost and the individual cost information.family cost and the individual cost information.What is the annual cost for family coverage?What is the annual cost for family coverage?$$What is the annual cost for individual coverage?What is the annual cost for individual coverage?$$Is a health insurance card available? Yes NoIs a health insurance card available? Yes NoAre insurance cards required for services? Yes NoAre insurance cards required for services? Yes NoDoes the plan cover hospitalization? Yes NoDoes the plan cover hospitalization? Yes NoIs there a deductible for services? Yes NoIs there a deductible for services? Yes NoIf yes, what is the deductible?If yes, what is the deductible? Check One:Check One:$$PerPer Visit Mo. Visit Mo. Yr YrIs there a co-payment required? Yes NoIs there a co-payment required? Yes NoIf yes, what is the co-payment?If yes, what is the co-payment? Check One:Check one:$$PerPer Visit Mo. Yr. Visit Mo. YrDoes the plan cover doctor visits? Yes NoDoes the plan cover doctor visits? Yes NoIs there a deductible for services? Yes Yes No NoIs there a deductible for services?If yes, what is the deductible?If yes, what is the deductible? Check One:Check One:$$PerPer Visit Visit Mo. Yr. Yr. Mo.Is there a co-payment required? Yes No No YesIs there a co-payment required?If yes, what is the co-payment?If yes, what is the co-payment? Check One:Check One:$$PerPer Visit Visit Mo. Yr. Yr. Mo.HIDA Page 3 of 52001 © American LegalNet, Inc.You are to disclose all requested information in the column for you and in the column for the other party.Part I (Continued)Part II (Continued) Husband / Father / OtherWife / Mother / OtherIs a prescription card available? Yes NoIs a prescription card available? Yes NoIs a co-payment required? Yes NoIs a co-payment required? Yes No If yes, what is the co-payment?If yes, what is the co-payment?$Per Prescription$Per PrescriptionIs dental coverage available? Yes NoIs dental coverage available? Yes No Insurer / Plan NamePhoneInsurer / Plan NamePhoneAddressAddressPolicy / Group #Policy / Group #Is there a cost for dental coverage? Yes NoIs there a cost for dental coverage? Yes NoSpecial Instruction -The court requires both theSpecial Instruction -The court requires both the family cost and the individual cost information.family cost and the individual cost information.What is the annual cost for family dental coverage?What is the annual cost for family dental coverage?$$What is the annual cost for individual dental coverage?What is the annual cost for individual dental coverage?$$Is a dental insurance card available? Yes NoIs a dental insurance card available? Yes No Are dental insurance cards requiredAre dental insurance cards requiredfor services? Yes Nofor services? Yes NoIs vision coverage available?Is vision coverage available? Yes No Yes No Insurer / Plan NamePhoneInsurer / Plan NamePhoneAddressAddressPolicy / Group #Policy / Group #HIDA Page 4 of 52001 © American LegalNet, Inc.You are to disclose all requested information in the column for you and in the column for the other party.Part I (Continued)Part II (Continued) Husband / Father / OtherWife / Mother / OtherIs there a cost for vision coverage? Yes No Is there a cost for vision coverage? Yes NoSpecial Instruction -The court requires both theSpecial Instruction -The court requires both the family cost and the individual cost information.family cost and the individual cost information.What is the annual cost for family vision coverage?What is the annual cost for family vision coverage?$$What is the annual cost for individual vision coverage?What is the annual cost for individual vision coverage?$$Is a vision insurance card available? Yes NoIs a vision insurance card available? Yes No Are vision insurance cards requiredAre vision insurance cards requiredfor services?for services? Yes No Yes NoIs COBRA insurance available? (A continuation of present insurance coverage after termination of employment or marriage)Is COBRA insurance available? (A continuation of present insurance coverage after termination of employment or marriage)If yes, at what cost?C