Rule 5101:12-57-99. Chapter 5101:12-57 forms - enforcement of medical support provisions

119.03 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 Supplemental Information Authorized By: 3125.25 Amplifies: 3125.03 2/16/2027 1/15/2017 Disclaimer Contact About