Objection to the National Medical Support Notice

2. OBJECTION TO THE NATIONAL MEDICAL SUPPORT NOTICE
   Please fill this form out completely. If required documentation is not given, it will not be taken into consideration for this objection. This form CANNOT be saved. You CANNOT leave this form and return to it at a later time. Please review this form to make sure you have everything needed to complete it once you begin.

   Please fill this form out completely. If required documentation is not given, it will not be taken into consideration for this objection. This form CANNOT be saved. You CANNOT leave this form and return to it at a later time. Please review this form to make sure you have everything needed to complete it once you begin.
4. First Name*
5. Last Name*
7. I object to the National Medical Support Notice (NMSN) that was sent to my employer.*
   Please indicate the name of your employer in which this document was sent.
9. Please provide the cost for you to provide health care coverage (i.e. insurance) for your child(ren) through the employer above
10. Cost to you per:

    1. Week
    2. Bi-weekly
    3. Semi-monthly
    4. Monthly
14. The specific reason for the objection is (select ONLY ONE):
16. 1.

    1. I am not ordered to provide insurance for the child(ren)
18. 2.

    1. The cost to provide insurance for the child(ren) is too much; it exceeds the reasonable cost determined by your order
20. Provide 3 pay stubs AND the cost of benefits information from your employer
    Please provide all documentation in one upload if possible. If not, please use the additional documentation upload.
22. Additional documentation upload
23. Additional documentation upload
25. 3.

    1. I am providing health care coverage for the child(ren) through other means

    I am providing health care coverage for the child(ren) through other means (e.g. I have the child[ren] on Medicaid, my spouse is covering the child[ren] on his/her insurance, I have insurance for the child[ren] through another employer, etc).
27. Provide a copy of BOTH SIDES of the health care coverage card
    Please upload a copy of both sides into one document if possible. If not, please use the additional documentation upload.
28. Additional documentation upload
30. **If you are not the subscriber (sponsor) of the health care coverage for the child(ren), print the name of the individual who is the subscriber (sponsor) for the coverage:
32. 4.

    1. The NMSN was sent for the wrong person; there is a mistake of identity
34. Please explain
36. Attach any proof that you have
38. 5.

    1. The health care coverage is not accessible to the child(ren) because the parent(s) must travel too far to obtain health care services for the child(ren)
40. 6.

    1. Other
42. Please explain and be specific
44. Documentation upload
    Please provide any documentation that supports your objection
48. Date*
    Date
49. Phone Number
51. Email Address
53. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
55. Electronic Signature*
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

* indicates a required field