Dcss 0054 Form PDF Details

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QuestionAnswer
Form NameDcss 0054 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesform dcss 0054, california health dcss get, dcss 0054, fillable dcss

Form Preview Example

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF CHILD SUPPORT SERVICES

HEALTH INSURANCE INFORMATION

DCSS 0054 (04/27/05)

County:

Phone:

LCSA Case Number:

 

Noncustodial Parent:

 

 

 

 

 

 

 

Full Name (First, Middle, Last, Suffix)

 

I am the

 

 

 

Custodial Party

Noncustodial Parent

 

 

Employer

 

Address (Street)

 

City, State, Zip Code

 

Phone

Social Security Number

Employer (Name, street, city, state, zip code, phone)

INSTRUCTIONS: Please complete SECTION I if health insurance is provided or available by the Noncustodial Parent or employer. SECTION II is about the other parent's insurance. Employers complete Sections I and III only. Please sign and date the completed form.

SECTION I: YOUR HEALTH INSURANCE

HEALTH INSURANCE:

Do you currently have Health Insurance coverage?

Yes

No

If Yes, please complete the following.

Health Insurance Company or Union (provide Union Local number)

 

Provided by:

 

 

 

 

 

 

Custodial Party

 

Noncustodial Parent

 

 

 

 

Employer

 

Other:

 

 

 

 

 

 

 

Relationship:

Insurance Company's Address: Street, Apartment Number or Unit Number

 

 

 

Telephone Number

(Address where claims are mailed)

 

 

 

 

 

(include Area Code)

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

Policy Number

 

 

 

 

 

 

 

 

Premium Amount $

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

 

 

 

Amount You Pay $

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

 

 

Amount Employer Pays $

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

 

Amount of deduction applied to employee's

Amount of deduction applied to dependent's portion of

Cost to add additional child

portion of Health Insurance $

Health Insurance $

 

 

$

 

Dependent(s) Currently Covered By Health Insurance

 

Name (First, Middle, Last)

Social Security

Sex

Date of Birth

Policy Number(s)

Start Date

End Date

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check this box if names and policy numbers of additional dependents covered by your Health Insurance are listed on a separate sheet. Please attach the sheet.

Not available to dependents

Page 1 of 3

The Policy covers the following: (Check all that apply)

 

 

Doctor Visits

Medicare Supplemental

Specific Illness

Prescription Drugs

Long Term Care

Hospital Stays

Hospital Outpatient

Other (Specify):

 

 

(i.e., lab work, physical therapy)

 

DENTAL INSURANCE:

 

Do you currently have Dental Insurance coverage?

Yes

No

 

 

If Yes, please complete the following.

 

 

 

Dental Insurance Company

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental Insurance Company's Address: Street, Apartment Number or Unit Number (address where claims are mailed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

 

 

Policy Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Premium Amount $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check One:

Weekly

Bi-Weekly

 

 

Semi-Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount You Pay $

 

 

Check One:

Weekly

Bi-Weekly

 

 

Semi-Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount Employer Pays $

 

 

Check One:

Weekly

Bi-Weekly

 

 

Semi-Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount of deduction applied to employee's

Amount of deduction applied to dependent's

 

Cost to add additional child

 

portion of Health Insurance $

 

 

portion of health insurance $

 

$

 

 

 

 

 

Dependent(s) Covered by Dental Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (First, Middle, Last)

 

Social Security

Sex

Date of Birth

 

Policy Number(s)

 

 

Start Date

 

End Date

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check this box if names and policy numbers of additional dependents covered by your Dental Insurance are listed on a separate sheet of paper. Please attach the sheet.

Not available to dependents

VISION INSURANCE:

Do you currently have Vision Insurance coverage?

Yes

No

If Yes, please complete the following.

Vision Insurance Company

 

 

 

Vision Insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City

State

 

Zip Code

 

 

Policy Number

 

 

 

 

 

 

 

 

Premium Amount $

 

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

 

 

 

Amount You Pay $

 

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

Amount Employer Pays $

 

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

Amount of deduction applied to employee's

Amount of deduction applied to dependent's portion

Cost to add additional child

portion of Health Insurance $

 

of health insurance $

 

 

 

$

Dependent(s) Covered by Vision Insurance

Name (First, Middle, Last)

Social Security

Sex

 

Number

 

1.

 

 

 

 

 

2.

 

 

 

 

 

3.

 

 

 

 

 

4.

 

 

 

 

 

5.

 

 

 

 

 

6.

 

 

 

 

 

Date of Birth

Policy Number(s)

Start Date

End Date

Please check this box if names and policy numbers of additional dependents covered by your Vision Insurance are listed on a separate sheet. Please attach the sheet.

Not available to dependents

HEALTH INSURANCE INFORMATION

Page 2 of 3

 

DCSS 0054 (04/27/05)

 

SECTION II: OTHER PARENT'S INSURANCE

HEALTH INSURANCE:

Does the other parent currently provide Health Insurance coverage for the child(ren) or you? Yes If Yes, please complete the following information.

No

Health Insurance Company

Health insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City

State

Zip Code

 

 

 

 

 

 

DENTAL INSURANCE:

 

 

 

 

Does the other parent currently provide Dental Insurance coverage for the child(ren) or you?

Yes

No

If Yes, please complete the following information.

 

 

 

Dental Insurance Company

 

 

 

 

Dental Insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City

State

Zip Code

 

 

 

 

 

 

 

VISION INSURANCE:

 

 

 

 

Does the other parent currently provide Vision Insurance coverage for the child(ren) or you?

Yes

No

If Yes, please complete the following information.

 

 

 

Vision Insurance Company

 

 

 

 

Vision Insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City

State

Zip Code

SECTION III: (MUST BE COMPLETED)

I have enclosed the insurance card(s)/information about the coverage for the child(ren).

At this time I do not have the insurance cards/information about the coverage for the child(ren). I will send the information to you when I get it from the insurance company.

At this time there is no health insurance coverage available. I understand that if it becomes available, I will have to add my child(ren) onto the plan and then notify the local child support agency of the coverage. Coverage is unavailable because:

Not offered

Seasonal

Part-Time

Refused enrollment

Unreasonable in cost

Probationary period/date eligible

PRIVACY STATEMENT

The information Practices Act of 1997 (Civil Code Section 1798.17) and the Federal Privacy Act of 1974 (Public Law 93-579) require this notice be provided when collecting personal information from individuals. Information requested on this form, including Social Security Number, is used by the Department of Child Support Services (DCSS) for purposes of identification and communication with you. The DCSS is required, under Section 466 (a)(13) of the Social Security Act, to collect the Social Security Number of any individual who is subject to a divorce decree, support order, or paternity determination or acknowledgement.

Social Security Number information is mandatory and will be kept on file at the local child support agency to locate and identify individuals and assets for the purpose of establishing, modifying, and enforcing child support obligations. Enrolling a child in health insurance may require the release of the child's Social Security Number and mailing address to the other parent's employer or the release of the child's Social Security Number to the other parent.

The information in your case may be discussed with or given to the State, other agencies that can legally receive such information, and to the other parent or his/her attorney to the extent required by law.

SIGNATURE

 

DATE

 

 

 

 

 

 

 

PRINTED NAME

TELEPHONE (include Area Code)

 

 

 

 

 

 

 

TITLE

 

 

 

 

 

 

 

HEALTH INSURANCE INFORMATION

 

Page 3 of 3

 

DCSS 0054 (04/27/05)

 

 

 

How to Edit Dcss 0054 Form Online for Free

It really is very easy to fill in the dcss health insurance information. Our software was intended to be assist you to prepare any PDF easily. These are the actions to go through:

Step 1: Find the button "Get Form Here" on this website and hit it.

Step 2: At the moment you're on the file editing page. You may modify and add text to the document, highlight specified content, cross or check particular words, include images, insert a signature on it, erase unneeded areas, or remove them entirely.

Enter the appropriate material in every section to prepare the PDF dcss health insurance information

dcss health insurance information form empty spaces to fill out

Indicate the data in City, State, Zip Code, Policy Number, Premium Amount, Amount You Pay, Amount Employer Pays, Check One, Weekly, Check One, Check One, Weekly, Weekly, BiWeekly, and BiWeekly.

dcss health insurance information form City, State, Zip Code, Policy Number, Premium Amount, Amount You Pay, Amount Employer Pays, Check One, Weekly, Check One, Check One, Weekly, Weekly, BiWeekly, and BiWeekly fields to fill

You'll be expected to provide the details to help the application complete the box The Policy covers the following, Doctor Visits, Long Term Care, Hospital Stays, DENTAL INSURANCE Do you currently, Specific Illness, Prescription Drugs, Hospital Outpatient ie lab work, Other Specify, Yes, If Yes please complete the, Dental Insurance Companys Address, City, State, and Zip Code.

Completing dcss health insurance information form part 3

Indicate the rights and obligations of the parties within the paragraph Please check this box if names and, VISION INSURANCE Do you currently, Yes, If Yes please complete the, Vision Insurance Companys Address, City, State, Zip Code, Policy Number, Premium Amount Amount You Pay, Check One, Check One, Weekly, Weekly, and BiWeekly.

dcss health insurance information form Please check this box if names and, VISION INSURANCE Do you currently, Yes, If Yes please complete the, Vision Insurance Companys Address, City, State, Zip Code, Policy Number, Premium Amount Amount You Pay, Check One, Check One, Weekly, Weekly, and BiWeekly fields to complete

Look at the fields Amount Employer Pays Amount of, Please check this box if names and, HEALTH INSURANCE INFORMATION DCSS, and Page of and thereafter fill them in.

Filling in dcss health insurance information form step 5

Step 3: Choose the Done button to save the form. So now it is available for export to your device.

Step 4: Just be sure to generate as many duplicates of your document as you can to avoid future problems.

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