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The DCSS 0054 form is a crucial document for managing health insurance information related to child support arrangements in the state of California. It serves as a method for noncustodial parents to provide essential details regarding their health, dental, and vision insurance coverage. This information is not only pertinent to the custodial party but also plays a vital role in ensuring that children receive necessary medical care without financial strain. Section I of the form focuses on the health insurance provided by the noncustodial parent or their employer, prompting the disclosure of specific details such as the insurance company's name, policy numbers, and coverage amounts. Meanwhile, Section II addresses whether the other parent provides any health insurance, asking similar questions regarding their coverage. The final section, Section III, requires further confirmation of insurance status and guidance on notifying the local child support agency about the existence or absence of coverage. Overall, the DCSS 0054 form is an essential tool in facilitating communication between parents and local child support agencies, ensuring compliance with support obligations and the well-being of children involved.

Dcss 0054 Example

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF CHILD SUPPORT SERVICES

HEALTH INSURANCE INFORMATION

DCSS 0054 (04/27/05)

County:

Phone:

LCSA Case Number:

 

Noncustodial Parent:

 

 

 

 

 

 

 

Full Name (First, Middle, Last, Suffix)

 

I am the

 

 

 

Custodial Party

Noncustodial Parent

 

 

Employer

 

Address (Street)

 

City, State, Zip Code

 

Phone

Social Security Number

Employer (Name, street, city, state, zip code, phone)

INSTRUCTIONS: Please complete SECTION I if health insurance is provided or available by the Noncustodial Parent or employer. SECTION II is about the other parent's insurance. Employers complete Sections I and III only. Please sign and date the completed form.

SECTION I: YOUR HEALTH INSURANCE

HEALTH INSURANCE:

Do you currently have Health Insurance coverage?

Yes

No

If Yes, please complete the following.

Health Insurance Company or Union (provide Union Local number)

 

Provided by:

 

 

 

 

 

 

Custodial Party

 

Noncustodial Parent

 

 

 

 

Employer

 

Other:

 

 

 

 

 

 

 

Relationship:

Insurance Company's Address: Street, Apartment Number or Unit Number

 

 

 

Telephone Number

(Address where claims are mailed)

 

 

 

 

 

(include Area Code)

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

Policy Number

 

 

 

 

 

 

 

 

Premium Amount $

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

 

 

 

Amount You Pay $

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

 

 

Amount Employer Pays $

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

 

Amount of deduction applied to employee's

Amount of deduction applied to dependent's portion of

Cost to add additional child

portion of Health Insurance $

Health Insurance $

 

 

$

 

Dependent(s) Currently Covered By Health Insurance

 

Name (First, Middle, Last)

Social Security

Sex

Date of Birth

Policy Number(s)

Start Date

End Date

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check this box if names and policy numbers of additional dependents covered by your Health Insurance are listed on a separate sheet. Please attach the sheet.

Not available to dependents

Page 1 of 3

The Policy covers the following: (Check all that apply)

 

 

Doctor Visits

Medicare Supplemental

Specific Illness

Prescription Drugs

Long Term Care

Hospital Stays

Hospital Outpatient

Other (Specify):

 

 

(i.e., lab work, physical therapy)

 

DENTAL INSURANCE:

 

Do you currently have Dental Insurance coverage?

Yes

No

 

 

If Yes, please complete the following.

 

 

 

Dental Insurance Company

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental Insurance Company's Address: Street, Apartment Number or Unit Number (address where claims are mailed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

 

 

Policy Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Premium Amount $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check One:

Weekly

Bi-Weekly

 

 

Semi-Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount You Pay $

 

 

Check One:

Weekly

Bi-Weekly

 

 

Semi-Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount Employer Pays $

 

 

Check One:

Weekly

Bi-Weekly

 

 

Semi-Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount of deduction applied to employee's

Amount of deduction applied to dependent's

 

Cost to add additional child

 

portion of Health Insurance $

 

 

portion of health insurance $

 

$

 

 

 

 

 

Dependent(s) Covered by Dental Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (First, Middle, Last)

 

Social Security

Sex

Date of Birth

 

Policy Number(s)

 

 

Start Date

 

End Date

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check this box if names and policy numbers of additional dependents covered by your Dental Insurance are listed on a separate sheet of paper. Please attach the sheet.

Not available to dependents

VISION INSURANCE:

Do you currently have Vision Insurance coverage?

Yes

No

If Yes, please complete the following.

Vision Insurance Company

 

 

 

Vision Insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City

State

 

Zip Code

 

 

Policy Number

 

 

 

 

 

 

 

 

Premium Amount $

 

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

 

 

 

Amount You Pay $

 

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

Amount Employer Pays $

 

 

Check One:

Weekly

Bi-Weekly

Semi-Monthly

 

 

 

 

 

Amount of deduction applied to employee's

Amount of deduction applied to dependent's portion

Cost to add additional child

portion of Health Insurance $

 

of health insurance $

 

 

 

$

Dependent(s) Covered by Vision Insurance

Name (First, Middle, Last)

Social Security

Sex

 

Number

 

1.

 

 

 

 

 

2.

 

 

 

 

 

3.

 

 

 

 

 

4.

 

 

 

 

 

5.

 

 

 

 

 

6.

 

 

 

 

 

Date of Birth

Policy Number(s)

Start Date

End Date

Please check this box if names and policy numbers of additional dependents covered by your Vision Insurance are listed on a separate sheet. Please attach the sheet.

Not available to dependents

HEALTH INSURANCE INFORMATION

Page 2 of 3

 

DCSS 0054 (04/27/05)

 

SECTION II: OTHER PARENT'S INSURANCE

HEALTH INSURANCE:

Does the other parent currently provide Health Insurance coverage for the child(ren) or you? Yes If Yes, please complete the following information.

No

Health Insurance Company

Health insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City

State

Zip Code

 

 

 

 

 

 

DENTAL INSURANCE:

 

 

 

 

Does the other parent currently provide Dental Insurance coverage for the child(ren) or you?

Yes

No

If Yes, please complete the following information.

 

 

 

Dental Insurance Company

 

 

 

 

Dental Insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City

State

Zip Code

 

 

 

 

 

 

 

VISION INSURANCE:

 

 

 

 

Does the other parent currently provide Vision Insurance coverage for the child(ren) or you?

Yes

No

If Yes, please complete the following information.

 

 

 

Vision Insurance Company

 

 

 

 

Vision Insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City

State

Zip Code

SECTION III: (MUST BE COMPLETED)

I have enclosed the insurance card(s)/information about the coverage for the child(ren).

At this time I do not have the insurance cards/information about the coverage for the child(ren). I will send the information to you when I get it from the insurance company.

At this time there is no health insurance coverage available. I understand that if it becomes available, I will have to add my child(ren) onto the plan and then notify the local child support agency of the coverage. Coverage is unavailable because:

Not offered

Seasonal

Part-Time

Refused enrollment

Unreasonable in cost

Probationary period/date eligible

PRIVACY STATEMENT

The information Practices Act of 1997 (Civil Code Section 1798.17) and the Federal Privacy Act of 1974 (Public Law 93-579) require this notice be provided when collecting personal information from individuals. Information requested on this form, including Social Security Number, is used by the Department of Child Support Services (DCSS) for purposes of identification and communication with you. The DCSS is required, under Section 466 (a)(13) of the Social Security Act, to collect the Social Security Number of any individual who is subject to a divorce decree, support order, or paternity determination or acknowledgement.

Social Security Number information is mandatory and will be kept on file at the local child support agency to locate and identify individuals and assets for the purpose of establishing, modifying, and enforcing child support obligations. Enrolling a child in health insurance may require the release of the child's Social Security Number and mailing address to the other parent's employer or the release of the child's Social Security Number to the other parent.

The information in your case may be discussed with or given to the State, other agencies that can legally receive such information, and to the other parent or his/her attorney to the extent required by law.

SIGNATURE

 

DATE

 

 

 

 

 

 

 

PRINTED NAME

TELEPHONE (include Area Code)

 

 

 

 

 

 

 

TITLE

 

 

 

 

 

 

 

HEALTH INSURANCE INFORMATION

 

Page 3 of 3

 

DCSS 0054 (04/27/05)

 

 

 

File Breakdown

Fact Name Detail
Form Title Health Insurance Information
Form Number DCSS 0054
Governing Law California Family Code Section 4000 et seq.
Primary Purpose To collect information regarding health insurance coverage for children involved in child support cases.
Completion Requirement Sections I, II, and III must be completed by relevant parties to ensure proper documentation of insurance coverage.

Guide to Using Dcss 0054

Filling out the DCSS 0054 form is essential for documenting health insurance information related to child support cases. After completing the form, you will submit it to the appropriate local child support agency. Ensure all information is accurate and complete to avoid delays in processing.

  1. Obtain the form: Download or print the DCSS 0054 form from the official site.
  2. Fill in the top section: Include the county, phone number, LCSA case number, and indicate whether you are the custodial or noncustodial parent.
  3. Section I - Health Insurance: Answer if you currently have health insurance. If yes, provide the insurance company’s name, address, policy number, and premium information. Detail the amount you pay and the amount your employer pays.
  4. Dependent Information: List the names, Social Security Numbers, dates of birth, and policy numbers of all dependents currently covered under your health insurance.
  5. Dental and Vision Insurance: Repeat the process for dental and vision insurance. Indicate whether you have coverage and provide the necessary details for each type.
  6. Section II - Other Parent's Insurance: Indicate if the other parent provides health, dental, or vision insurance for the child. Fill in the relevant details if applicable.
  7. Section III: Confirm whether you have insurance cards/information available. If not, state the reason insurance is unavailable.
  8. Signature: Sign and date the form at the bottom. Ensure all information is correct before submission.

Get Answers on Dcss 0054

What is the DCSS 0054 form used for?

The DCSS 0054 form is a Health Insurance Information form used by the California Department of Child Support Services. It collects information about existing health, dental, and vision insurance coverage for children involved in child support cases. This ensures that both parents are informed about insurance options available for their children.

Who needs to fill out the DCSS 0054 form?

Both custodial and noncustodial parents may need to complete the form. If a noncustodial parent has health insurance or the employer provides it, Section I of the form must be filled out. Additionally, custodial parents must provide information regarding any other health insurance available for the child.

What information do I need to provide on the DCSS 0054 form?

You will provide comprehensive details about health insurance coverage, including:

  • Your health insurance provider's name and address.
  • Policy numbers and the coverage start and end dates.
  • Premium amounts and any deductions for employee and dependent portions.
  • Information about dependents currently covered by the insurance.

For dental and vision insurance, similar information is required. Fill out the sections relevant to your situation.

What happens if I don't have health insurance for my child?

If you do not currently have health insurance available, you should indicate this on the form. You are also required to explain the reasons why coverage is unavailable. For instance, you might be unable to enroll due to costs, lack of availability, or a probationary period in your employment.

When must I submit the DCSS 0054 form?

The form must be submitted whenever you receive a request from the local child support agency or when there is a change in health insurance coverage for your child. Timely submission ensures that the local agency can assist in keeping your child's insurance information up to date.

Is my personal information safe when I fill out the DCSS 0054 form?

Your privacy is protected by law. The information collected in the DCSS 0054 form is used solely for purposes related to child support and is subject to strict confidentiality regulations. The Department of Child Support Services ensures compliance with privacy laws to keep your data secure.

Common mistakes

When filling out the DCSS 0054 form, many individuals encounter common pitfalls that can lead to delays or complications in processing. One frequent mistake is leaving out essential information, particularly in the sections related to health insurance providers. If these fields are left blank, it may hinder the local child support agency's ability to verify coverage and communicate effectively.

Another common error involves misidentifying the noncustodial parent or custodial party. It’s crucial to ensure that the names are entered accurately as they appear on legal documents. An incorrect name can complicate the entire process, causing unnecessary confusion.

Many people also fail to provide complete addresses for health insurance companies and employers. The form requests specific details, such as the street address and zip code; omitting these can lead to delays since the agency may not be able to contact the relevant parties.

A significant oversight is not checking the appropriate boxes regarding existing insurance coverage. If you indicate "Yes" to having insurance when that's not accurate, it sets a false premise for further processing. Conversely, saying "No" when you do have coverage can have serious implications for support obligations.

Completing monetary fields incorrectly is another mistake often made. It's vital to accurately represent premium amounts and select the correct payment frequency. A discrepancy may lead to misunderstandings about financial responsibilities.

Failing to attach additional documents can also cause issues. If there are more dependents covered by your health insurance, make sure to include a separate sheet as requested. Not doing so can result in an incomplete submission, requiring follow-up.

In the section regarding the other parent's insurance, many individuals neglect to provide all required details or simply leave it blank. If the other parent has health insurance, it is necessary to fill in that information as it may affect support calculations.

Even minor mistakes, like writing illegibly or using the wrong format for dates, can complicate matters. Ensure that all entries are clear and conform to the specified formats to avoid confusion.

Additionally, forgetting to sign and date the form is a simple yet critical error. An unsigned form is often deemed invalid, necessitating a complete restart of the submission process.

Finally, individuals sometimes overlook important background information, such as the reason for lack of coverage, if applicable. This information can be pertinent and may influence future decisions regarding support and healthcare options.

Documents used along the form

The DCSS 0054 form plays a pivotal role in gathering health insurance information related to child support cases in California. Several other forms and documents can complement this form, ensuring a comprehensive understanding of a child's insurance coverage. Each of these documents serves a specific purpose, contributing to the overall complexity of child support and welfare cases.

  • DCSS 0010 - Applications for Child Support Services: This form initiates the process for receiving child support services. Families seeking support must fill it out to begin the administrative process and benefit from available resources.
  • DCSS 0017 - Request for Hearing: If any party involved in a child support case disputes the findings or orders, this form requests a formal hearing. It allows parents to present their case and seek a resolution.
  • DCSS 0026 - Summary of Child Support Payments: This document outlines the payment history for child support obligations. It serves as a vital record for tracking payments made or received, ensuring accountability on both sides.
  • DCSS 0030 - Income and Expense Declaration: Parties must complete this form to provide a detailed account of their financial situation. This helps in determining each parent’s ability to pay child support as well as the child’s needs.
  • DCSS 0037 - Notice of Wage Assignment: This form notifies an employer about a noncustodial parent's obligation to pay child support directly from their wages. It ensures the timely deduction of payments from the parent’s salary.
  • DCSS 0064 - Health Insurance Addendum: This addendum supplements health information. It is used when additional details about health coverage are needed that are not adequately addressed by the primary DCSS 0054 form.

Understanding these forms enhances one's ability to navigate the complexities of child support and health insurance requirements. It is crucial for all parties involved to be informed about the necessary documentation, as this can have a lasting impact on the welfare of the child and the financial responsibilities of the parents.

Similar forms

The DCSS 0054 form, which focuses on health insurance information for child support cases, has several similar documents that serve related purposes. Below is a list of these documents, each accompanied by a brief description of how they relate to the DCSS 0054 form.

  • Child Support Worksheet: This document outlines the financial circumstances of both parents, determining the amount of support due. Like the DCSS 0054, it emphasizes financial considerations relevant to child welfare.
  • Health Insurance Verification Form: This form also seeks information about available health insurance for children and is critical for determining coverage and out-of-pocket costs, similar to the DCSS 0054.
  • Medical Support Order: Issued by a court, this document establishes the responsibility for providing health insurance for children, mirroring the intention behind the DCSS 0054.
  • Dependent Care Assistance Form: This document collects information about child care expenses. It works in conjunction with the DCSS 0054 to assess overall support needs.
  • Medicaid Application: This document is used to apply for health coverage for low-income families. It shares the common goal of ensuring children have access to necessary medical care, like the DCSS 0054.
  • Insurance Coordination of Benefits Form: Used to determine which insurance is primary when multiple plans cover a child, this form complements the DCSS 0054 in ensuring comprehensive coverage.
  • Child Medical Expense Verification Form: This document is submitted to confirm health care expenditures, ensuring transparency and accountability, similar to the way the DCSS 0054 handles insurance coverage disclosures.
  • Parenting Plan Template: This document outlines the responsibilities of each parent regarding health care, among other issues. It relates closely to the DCSS 0054, as both address parental obligations.
  • Child Health Assessment Form: This form gathers health history and concerns for children. Its use ensures that a child’s medical needs are documented, paralleling the health focus seen in the DCSS 0054.

Each of these documents plays a crucial role in the broader context of child support and health care provisions, reinforcing the importance of ensuring that children receive the necessary support and care.

Dos and Don'ts

When filling out the DCSS 0054 form, adhere to the following guidelines.

  • Do: Clearly state the full name of the noncustodial parent as it appears on official documents.
  • Do: Provide complete and accurate details about your health, dental, and vision insurance coverage.
  • Do: Sign and date the form to validate your submission.
  • Do: Attach any additional sheets if you have more dependents covered by your insurance.
  • Do: Contact the local child support agency if you're unsure about any section.
  • Don't: Skip sections that do not apply to you; marking "N/A" is better than leaving them blank.
  • Don't: Provide outdated or incorrect information; double-check policy numbers and contact details.
  • Don't: Forget to include your Social Security number; it is mandatory for processing.
  • Don't: Submit the form without reviewing it carefully for errors or omissions.
  • Don't: Delay in notifying the local agency if your insurance information changes.

Misconceptions

  • Misconception 1: The DCSS 0054 form is only for custodial parents.
  • This form is necessary for both custodial and noncustodial parents. It collects information about health insurance coverage for children, which applies to both parties involved in child support agreements.

  • Misconception 2: Completing the form is optional.
  • Filing the DCSS 0054 form is typically mandatory when health insurance is available. Failing to provide this information may affect child support calculations and obligations.

  • Misconception 3: The form only pertains to medical insurance.
  • While the primary focus is on health insurance, the DCSS 0054 form also gathers details about dental and vision insurance coverage, ensuring comprehensive health support for the child.

  • Misconception 4: It's unnecessary to update the form after initial submission.
  • Changes in insurance status, such as job changes or new coverage options, require updates to the DCSS 0054 form. Keeping this information current is crucial for accurate support and care decisions.

  • Misconception 5: All information provided is kept confidential.
  • While privacy is a priority, certain details, especially Social Security Numbers, may be shared with relevant parties, including the other parent or their employer, as required by law.

  • Misconception 6: Only one parent needs to provide insurance information.
  • Both parents must complete the necessary sections regarding their respective insurance coverage. This collaborative approach ensures that all potential sources of health care are considered for the child.

  • Misconception 7: The form is outdated and no longer in use.
  • The DCSS 0054 form remains a vital part of the child support process. Despite being first issued in 2005, it continues to be relevant for parents navigating child support and health insurance obligations today.

Key takeaways

When completing and using the DCSS 0054 form, it's important to follow certain guidelines to ensure that the process goes smoothly. Below are some key takeaways:

  • Completing the correct sections is crucial. Section I is for health insurance information about the noncustodial parent or their employer, while Section II pertains to any health insurance the other parent may provide.
  • Be thorough when listing dependents. If there are more dependents than can fit in the form, include their names and policy numbers on a separate sheet and attach it.
  • All relevant insurance information must be accurate, including policy numbers and coverage details. Failing to provide this may lead to delays in processing.
  • It is essential to confirm that the form is signed and dated. This final step certifies the accuracy of the information provided and is a requirement for submission.