Health Insurance Status Change Form {3F012}

Office of the Attorney General MEDICAL SUPPORT UNIT P.O. BOX 1328 AUSTIN, TX 78767-13285 Toll-Free (800) 522-2421 Fax (855) 329-6676 Bar code Area (w/ FSN) <F019> FS# <F019> <F004> <F005> <F006> <F007> <F008> <F009> <F010> Date: <F002> Custodial Parent <F032> <F034> Non-Custodial Parent: <F024> <F026> Attorney General Case # <F003> Cause # <F040> HEALTH INSURANCE STATUS CHANGE FORM Employers are required to notify the Office of the Attorney General of a change of status of an employee [Texas Family Code, 154.187 and 158.211. Please keep this form for use as needed. If there is a change in the employee's health insurance or employment status, please complete this form and return it to: Medical Support Unit P.O. Box 1328 Austin, TX 78767-1328 If you have any questions, please call (800) 522-2421. For information about providing this information via the Internet, please visit www.employer.texasattorneygeneral.gov. Obligor: <F024><F025><F026> Date of occurrence: __________________________ Social Security Number: <F022> Attorney General Case #: <F003> This is to advise of a change in employment status between the above obligor and this employer [ ] The obligor is no longer employed by this employer; income withholding will stop on ___________________ (Notification of withholding interruption must be made within 7 days.) The obligor's last known home address: ________________________________________________ ________________________________________________ Telephone Number: _______________________________ The obligor's new employer name and address if known: ________________________________________________ ________________________________________________ ________________________________________________ [ ] Health insurance coverage has lapsed. Notification of insurance interruption must be within 15 days of occurrence. If the obligor is eligible for health insurance conversion privileges (COBRA), please enclose information. _____________________________________________________ Signature of Person Completing Form _____________________________________________________ Position/Title _____________________________________________________ Internet/Web Address November 2014 3F012 American LegalNet, Inc. www.FormsWorkFlow.com ________________________________ Date Form Completed ________________________________ (Area Code) Telephone Number November 2014 3F012 American LegalNet, Inc. www.FormsWorkFlow.com