The following disclosure may be included in the initial pleading or filed separately. See Tex. Fam. Code §§ 154.181(b), 154.1815(c).
NOTICE: THIS DOCUMENT
CONTAINS SENSITIVE DATA
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See § 6 of the Introduction in volume 1 of this manual concerning protection of sensitive data in filed documents. |
[Caption. See § 3 of the Introduction in volume 1 of this manual.]
Statement of Health Insurance and Dental Insurance Availability
This statement is made by [name], [party designation], in accordance with sections 154.181 and 154.1815 of the Texas Family Code.
1.Child[ren]
1. Child[ren]
The following child[ren] [is/are] the subject of this suit:
Name:
Birth date:
Social Security number:
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Repeat above information for each additional child. |
2.Health Insurance Availability
2. Health Insurance Availability
2.A.Private Health Insurance in Effect
Private health insurance is in effect for the child[ren], [name[s]].
Name of insurance company:
Policy number:
Party responsible for premium:
Monthly cost of premium:
The insurance coverage [is/is not] provided through a parent’s employment.
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Or |
2.B.Private Health Insurance Not in Effect
Private health insurance is not in effect for the child[ren], [name[s]].
The child[ren] [is/is not/are/are not] receiving Medicaid benefits under chapter 32, Human Resources Code.
The child[ren] [is/is not/are/are not] receiving health benefits coverage under the Children’s Health Insurance Program under chapter 62 of the Texas Health and Safety Code. [Include if applicable: The cost of the premium is $[amount].]
[Name], [mother/father] of the child[ren], [has/does not have] access to private health insurance at reasonable cost to [her/him]. [Name], [father/mother] of the child[ren], [has/does not have] access to private health insurance at reasonable cost to [him/her].
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Include the following if applicable. |
2.C.Application for Medicaid or CHIP
[Name] has applied for [Medicaid benefits for the child[ren]/coverage for the child[ren] under the Children’s Health Insurance Program]. The status of the application is [specify].
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Continue with the following. |
3.Dental Insurance Availability
3. Dental Insurance Availability
3.A.Dental Insurance in Effect
Dental insurance is in effect for the child[ren], [name[s]].
Name of insurance company:
Policy number:
Party responsible for premium:
Monthly cost of premium:
The insurance coverage [is/is not] provided through a parent’s employment.
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Or |
3.B.Dental Insurance Not in Effect
Private dental insurance is not in effect for the child[ren], [name[s]].
[Name], [mother/father] of the child[ren], [has/does not have] access to dental insurance at reasonable cost to [her/him]. [Name], [father/mother] of the child[ren], [has/does not have] access to dental insurance at a reasonable cost to [him/her].
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Continue with the following. |
Date: ______________________________.
[Name of party completing form]
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Forms 56-3 and 56-4 are reserved. |