NATIONAL MEDICAL SUPPORT NOTICE – ADDENDUM TO PART-B
Issuing Agency: |
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Court or Administrative Authority: |
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Issuing Agency Address: |
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Order Date: |
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Notice Date: |
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Order Identifier: |
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CSE Agency Case Identifier: |
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Document Tracking Identifier: |
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Telephone Number: |
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Employer web site: |
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FAX Number: |
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See NMSN Instructions: |
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http://www.acf.hhs.gov/programs/css/resource/national-medical-support-notice-form |
SECTION 1: HEALTH INSURANCE DETAILS
Use section 1-1 through 1-6 to provide the provider, policy and group numbers of the plans child (ren) is/are enrolled.
SECTION 1-1: MEDICAL INSURANCE
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Insurance Provider Name |
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Group Number |
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Policy Number |
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Insurance Provider Address Line 1 |
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Insurance Provider Address Line 2 |
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Insurance Provider City |
State |
Zip Code |
Zip Code Ext |
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Medical Insurance Coverage also Includes: (Check all that apply) |
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Dental |
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Vision |
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Prescription |
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Mental Health |
☐ |
Other (Specify): |
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SECTION 1-2: DENTAL INSURANCE
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Insurance Provider Name |
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Group Number |
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Policy Number |
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Insurance Provider Address Line 1 |
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Insurance Provider Address Line 2 |
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Insurance Provider City |
State |
Zip Code |
Zip Code Ext |
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SECTION 1-3: VISION INSURANCE
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Insurance Provider Name |
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Group Number |
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Policy Number |
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Insurance Provider Address Line 1 |
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Insurance Provider Address Line 2 |
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Insurance Provider City |
State |
Zip Code |
Zip Code Ext |
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SECTION 1-4: PRESCRIPTION DRUG INSURANCE
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Insurance Provider Name |
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Group Number |
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Policy Number |
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Insurance Provider Address Line 1 |
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Insurance Provider Address Line 2 |
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Insurance Provider City |
State |
Zip Code |
Zip Code Ext |
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SECTION 1-5: MENTAL HEALTH INSURANCE
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Insurance Provider Name |
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Group Number |
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Policy Number |
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Insurance Provider Address Line 1 |
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Insurance Provider Address Line 2 |
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Insurance Provider City |
State |
Zip Code |
Zip Code Ext |
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SECTION 1-6: OTHER INSURANCE
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Insurance Provider Name |
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Group Number |
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Policy Number |
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Insurance Provider Address Line 1 |
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Insurance Provider Address Line 2 |
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Insurance Provider City |
State |
Zip Code |
Zip Code Ext |
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SECTION 2: NO LONGER ELIGIBLE CHILDREN DETAILS
Use below section to list child(ren) who are at or above the age at which dependents are no longer eligible for coverage under the plan
Name (Last, First, Middle) |
Gender
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Date of Birth |
Social Security Number |
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Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Venkatesan, Guru [US-IN] |
File Modified | 0000-00-00 |
File Created | 2021-01-13 |