National Medical Support Notice - Part B

National Medical Support Notice - Part B

NMSN Part B page 1 053012 (3)

National Medical Support Notice - Part B

OMB: 1210-0113

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NATIONAL MEDICAL SUPPORT NOTICE - PART B

MEDICAL SUPPORT NOTICE TO PLAN ADMINISTRATOR


This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement Income Security Act of 1974 (ERISA), and for State and local government and church plans, sections 401(e) and (f) of the Child Support Performance and Incentive Act of 1998 (CSPIA). Receipt of this Notice from the Issuing Agency constitutes receipt of a Medical Child Support Order under applicable law. The rights of the parties and the duties of the plan administrator under this Notice are in addition to the existing rights and duties established under such law. The information on the Custodial Parent and Child(ren) contained on this page is confidential and should not be shared or disclosed with the employee. NOTE: For purposes of this form, the Custodial Parent may also be the employee when the State opts to enforce against the Custodial Parent.



Issuing Agency: ________________________________

Issuing Agency Address: ________________________

_____________________­________________________

Notice Date: __________________________________

CSE Agency Case Identifier: ______________________

Telephone Number:______________________________

FAX Number:___________________________________



Court or Administrative Authority: __________________

Order Date: ___________________________________

Order Identifier: ________________________________

Document Tracking Identifier: ___­__________________

Employer web site: _____________________________

See NMSN Instructions: www.acf.hhs.gov/programs/cse/forms/




_________________________________________

Employer/Withholder’s Federal EIN Number

_________________________________________

Employer/Withholder’s Name

_________________________________________

_________________________________________

_________________________________________

Employer / Withholder’s Address


_________________________________________

Custodial Parent’s Name (Last, First, MI)

_________________________________________

_________________________________________

_________________________________________

Custodial Parent’s Mailing Address

_________________________________________

_________________________________________

_________________________________________

Child(ren)’s Mailing Address (if different from Custodial Parent’s)

_________________________________________

Name and Telephone of a Representative of the Child(ren)


Child(ren)’s Name(s Gender DOB SSN

____________________ _____ ________ _____

____________________ _____ ________ _____

____________________ _____ ________ _____




RE: ____________________________________________

Employee’s Name (Last, First, MI) ____________________________________________

Employee’s Social Security Number

____________________________________________ ____________________________________________

____________________________________________

Employee’s Mailing Address

____________________________________________

Substituted Official/Agency Name

____________________________________________

____________________________________________

____________________________________________

Substituted Official/Agency Address

(Required if Custodial Parent’s mailing address is left blank)



____________________________________________

____________________________________________

____________________________________________

Mailing Address of a Representative of the Child(ren)



Child(ren)’s Name(s) Gender DOB SSN

____________________ _____ ________ ________

____________________ _____ ________ ________

____________________ _____ ________ ________





The order requires the child(ren) to be enrolled in  all health coverages available; or only the following coverage(s):  Medical;  Dental;  Vision;  Prescription drug;  Mental health;  Other (specify):________________________




OMB control number: 1210-0113 Expiration Date: 10/31/2015.


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