Motion for Reimbursement of Health Care Expenses

Motion for Reimbursement of Health Care Expenses

Please provide all required information to prepare your motion for reimbursement of health care expenses.
NRS240A DISCLOSURE - Read Carefully.

I, DEBORAH BARNHART, DOING BUSINESS AS DPS OF NORTHERN NEVADA, AM NOT AN ATTORNEY IN THE STATE OF NEVADA. I AM NOT AUTHORIZED TO GIVE LEGAL ADVICE OR LEGAL REPRESENTATION. I MAY NOT ACCEPT FEES FOR GIVING LEGAL ADVICE OR LEGAL REPRESENTATION.
Current Case Information

Enter details exactly as they appear in your court documents.
County*
Case No.*
Dept. No.
Plaintiff/Petitioner Name as it appears on the Court documents*

First NameLast Name
Defendant/Respondent Name as it appears on the Court documents*

First NameLast Name
Moving Party Information (Person Filing)

Enter your (the filing party's) information.
Full Legal Name*

First NameMiddle NameLast NameSuffix
Physical Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is your mailing address the same as your physical address?*

YesNo
Mailing Address (if different)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Telephone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Respondent Information (Other Party)

Enter the other party's information.
Full Legal Name (Respondent)*

First NameMiddle NameLast NameSuffix
Physical Address (Respondent)*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is the respondent's mailing address the same as their physical address?*

YesNo
Mailing Address (Respondent, if different)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Telephone Number (Respondent)*
Please enter a valid phone number.
Email Address (Respondent)*
example@example.com
Is the respondent represented by an attorney?*

YesNo
Respondent's Attorney Name*

First NameMiddle NameLast Name
Law Firm (optional)
Bar Number (Attorney)*
Attorney Physical Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is the attorney's mailing address the same as their physical address?*

YesNo
Attorney Mailing Address (if different)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Attorney Telephone Number*
Please enter a valid phone number.
Attorney Email Address*
example@example.com
Child(ren) Covered by Health Care Expenses

Add each child for whom you are seeking reimbursement.
Children Covered*
Date of Prior Order Requiring Payment*

MonthDayYear
Date
Totals / Amounts Owed

Enter the amounts as shown on your documentation. Use $0 if not applicable.
Total amount of health care bills not covered by insurance ($)*
Amount moving party has paid toward uncovered amount ($)*
Total amount still owed on outstanding bills ($)*
Amount other party owes to moving party as reimbursement ($)*
Health Care Expense Line Items

List each health care expense for which you seek reimbursement. Add a row for each expense.
Health Care Expense Line Items*
Service / Notice to Other Parent

Provide details about how and when you notified the other parent of these expenses.
Date bill(s) and proof(s) of payment were sent to other parent

MonthDayYear
Date
Method of Sending
If other, provide details
Exhibits

Upload required and additional supporting documents.
Upload: Insurance company payments (Exhibit 1)*

Cancelof
Upload: Proof of payments made by moving party (Exhibit 2)*

Cancelof
Additional Exhibits (optional)
NRS240A DISCLOSURE - Read Carefully

Please review and confirm the information below.
I, DEBORAH BARNHART, DOING BUSINESS AS DPS OF NORTHERN NEVADA, AM NOT AN ATTORNEY IN THE STATE OF NEVADA. I AM NOT AUTHORIZED TO GIVE LEGAL ADVICE OR LEGAL REPRESENTATION. I MAY NOT ACCEPT FEES FOR GIVING LEGAL ADVICE OR LEGAL REPRESENTATION.*

I understand that Deborah Barnhart, dba DPS of Northern Nevada, is not an attorney and is acting solely as a legal document preparer.
Date*

MonthDayYear
Date
Printed Name*

First NameMiddle NameLast Name
Should be Empty:

Motion for Reimbursement of Health Care Expenses

NRS240A DISCLOSURE - Read Carefully.

Current Case Information

Moving Party Information (Person Filing)

Respondent Information (Other Party)

Child(ren) Covered by Health Care Expenses

Totals / Amounts Owed

Health Care Expense Line Items

Service / Notice to Other Parent

Exhibits

NRS240A DISCLOSURE - Read Carefully