Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the child’s name in the designated field.
3. Next, fill in the date of service, along with the name of the health care provider.
4. Indicate what the expense was for in the respective section.
5. Record the original total charge provided by the health care provider in the appropriate field.
6. Deduct the amount that insurance paid from the original total charge to determine the uninsured amount.
7. Next, subtract any balance of “ordinary” health care expenses (up to $100) from the uninsured amount.
8. This will give you the uninsured “extraordinary” health care expense that needs to be divided between parents.
9. Input each parent's percentage of “extraordinary” health care expenses under court order.
10. Multiply each parent's portion of the total uninsured bill by their respective percentages.
11. Subtract any amounts already paid to the health care provider by each parent from this total.
12. This calculation will yield the amount each parent owes to the provider or as reimbursement to the other parent.
13. Select who prepared the form by checking the relevant option (mother or father).
14. Record the date the form was provided to the other parent and specify how it was provided.
15. Remember to attach copies of the health care bill and any explanations of benefits from the insurance company.
16. Finally, save changes to the form. You can download, print, or share the completed form as needed.

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