Rule 5101:12-57-99 | Chapter 5101:12-57 forms - enforcement of medical support provisions.
The forms identified in this rule are referenced within various rules contained within division 5101:12 of the Administrative Code. The effective or revised effective dates of the forms are as follows:
(A) JFS 03377, "Employer/Health Plan Administrator Health Insurance Verification Request" (rev. 1/2015);
(B) JFS 03399, "Notice of Administrative Mistake of Fact Hearing" (rev. 10/2019);
(C) JFS 04031, "Notice Regarding Cash Medical Support Order"(rev. 5/2025);
(D) JFS 04032, "Notice to Provide Cash Medical Support"(rev. 5/2025);
(E) JFS 04033, "Notice to Provide Private Health Insurance"(rev. 5/2025);
(F) JFS 04034, "Notice of Selection of Health Plan Option" (rev. 1/2015);
(G) JFS 04035, "Notice of Available Health Plan Options" (rev. 4/2022);
(H) JFS 04036, "Notice of Medical Support Enforcement Activity" (rev. 10/2019);
(I) JFS 04037, "Medical Support Enforcement Administrative Mistake of Fact Hearing Decision" (rev. 10/2019);
(J) JFS 04098, "Notice Regarding National Medical Support Notice Withholding Requirements" (rev. 1/2015);
(K) JFS 07053, "Notice of Medical Support Mistake of Fact Hearing" (rev. 5/2025);
(L) JFS 07058, "Medical Support Mistake of Fact Hearing Determination" (rev. 5/2025); and
(M) OMB 0970-0222, "National Medical Support Notice" (NMSN) (www.acf.hhs.gov/css).
Last updated June 29, 2025 at 10:09 PM
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