e-NMSN__Addendum 5 18 20

National Medical Support Notice-Part B

e-NMSN__Addendum 5 18 20

OMB: 1210-0113

Document [docx]
Download: docx | pdf

NATIONAL MEDICAL SUPPORT NOTICE – ADDENDUM TO PART-B


Issuing Agency:


Court or Administrative Authority:


Issuing Agency Address:


Order Date:


Notice Date:


Order Identifier:


CSE Agency Case Identifier:


Document Tracking Identifier:


Telephone Number:


Employer web site:


FAX Number:


See NMSN Instructions:




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






Insurance Provider Name


Group Number


Policy Number






Insurance Provider Address Line 1


Insurance Provider Address Line 2









Insurance Provider City

State

Zip Code

Zip Code Ext



Medical Insurance Coverage also Includes: (Check all that apply)



Dental

Vision

Prescription

Mental Health

Other (Specify):





SECTION 1-2: DENTAL INSURANCE






Insurance Provider Name


Group Number


Policy Number






Insurance Provider Address Line 1


Insurance Provider Address Line 2









Insurance Provider City

State

Zip Code

Zip Code Ext



SECTION 1-3: VISION INSURANCE






Insurance Provider Name


Group Number


Policy Number






Insurance Provider Address Line 1


Insurance Provider Address Line 2









Insurance Provider City

State

Zip Code

Zip Code Ext



SECTION 1-4: PRESCRIPTION DRUG INSURANCE






Insurance Provider Name


Group Number


Policy Number






Insurance Provider Address Line 1


Insurance Provider Address Line 2









Insurance Provider City

State

Zip Code

Zip Code Ext








SECTION 1-5: MENTAL HEALTH INSURANCE






Insurance Provider Name


Group Number


Policy Number






Insurance Provider Address Line 1


Insurance Provider Address Line 2









Insurance Provider City

State

Zip Code

Zip Code Ext




SECTION 1-6: OTHER INSURANCE






Insurance Provider Name


Group Number


Policy Number






Insurance Provider Address Line 1


Insurance Provider Address Line 2









Insurance Provider City

State

Zip Code

Zip Code Ext








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


Date of Birth

Social Security Number










































Page 4 of 4


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorVenkatesan, Guru [US-IN]
File Modified0000-00-00
File Created2021-04-06

© 2024 OMB.report | Privacy Policy