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. 10/2019);

(D)JFS 04032, "Notice to Provide Cash Medical Support"(rev. 10/2019);

(E)JFS 04033, "Notice to Provide Private Health Insurance"(rev. 10/2019);

(F)JFS 04034, "Notice of Selection of Health Plan Option" (rev. 1/2015);

(G)JFS 04035, "Notice of Available Health Plan Options" (rev. 1/20154/2022);

(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. 3/2019);

(L)JFS 07058, "Medical Support Mistake of Fact Hearing Determination" (rev. 2/2019); and

(M)OMB 0970-0222, "National Medical Support Notice" (NMSN) (www.acf.hhs.gov/css).

Effective: 6/1/2022

Five Year Review (FYR) Dates: 2/16/2022 and 02/16/2027

Certification: CERTIFIED ELECTRONICALLY

Date: 05/17/2022

Promulgated Under: 119.03

Statutory Authority: 3125.25.

Rule Amplifies: 3125.03.

Prior Effective Dates: 01/01/2015, 01/15/2017, 02/14/2019, 01/15/2020