How to Fill Out California Form FL-192 (w/Examples) + FAQs

California Form FL-192 is the Judicial Council’s official “Notice of Rights and Responsibilities — Health-Care Costs and Reimbursement Procedures,” and you do not actually fill it out — the court attaches it automatically to every child support order to inform both parents of their duties under California Family Code §§ 4061–4063. The form is purely informational, but ignoring its rules can trigger contempt, wage garnishment, and money judgments against the parent who refuses to pay or reimburse uninsured medical costs.

According to the California Department of Child Support Services, more than 1.1 million open child support cases exist in California, and uninsured health-care reimbursement disputes are among the top three enforcement issues filed each year. That single statistic shows why every parent under a support order must read FL-192 carefully and follow its 30-day rules.

In this guide, you will learn:

• 📋 What FL-192 really is and why the court attaches it to your order
• ⏱️ The strict 30-day reimbursement window and what happens if you miss it
• 💵 How to calculate each parent’s share of uninsured medical, dental, vision, and orthodontic costs
• ⚖️ How to enforce or defend a claim using Form FL-490 and contempt procedures
• 🛡️ The most common mistakes parents make and how to avoid losing thousands of dollars

What FL-192 Really Is (and Is Not)

Form FL-192 is a two-page notice issued by the Judicial Council of California. The court clerk staples it to every child support judgment, stipulation, or order. The form is mandatory under California Rules of Court, Rule 5.275, and judges cannot waive it.

The form does not require signatures, dates, or boxes to check. Parents do not draft it, and lawyers do not customize it. Instead, it lists the rights and duties created by Family Code § 4063 and the insurance-assignment rules in Family Code § 3751.

Many parents wrongly believe FL-192 is optional reading. The plain-English meaning is that the form binds both parents the moment the support order is signed. The consequence of ignoring the form is that a judge will still hold you to every rule inside it, even if you never opened the envelope. A common misconception is that FL-192 only applies when child support is ordered — in reality, it applies to any order that addresses health-care costs, including spousal-support files with minor children.

The Statutory Backbone

FL-192 mirrors three statutes. Family Code § 4061 splits uninsured costs equally unless the court orders a different ratio. Family Code § 4062 defines mandatory and discretionary “add-on” expenses. Family Code § 4063 sets the 30-day notice and 30-day payment rules.

Each statute carries a real penalty. A parent who hides a bill for more than a year may lose the right to seek reimbursement under § 4063(b). A parent who refuses to pay within 30 days of receiving proof faces interest at 10% per year under Code of Civil Procedure § 685.010.

Who Receives FL-192

Both parents receive a copy when the Income and Expense Declaration (FL-150) is filed and the child support order is entered. The local child support agency also receives a copy in IV-D cases handled by the Department of Child Support Services. Stepparents, grandparents, and guardians named in the order also receive notice if they share custody.

Line-By-Line Walk-Through of FL-192

Although you do not “fill in” FL-192, you must understand each numbered paragraph. The court will assume you read every line. Below is a guided walk-through using the official 2024 revision of the form.

Paragraph 1 — Health Insurance Coverage

This paragraph orders the parent who carries health insurance to keep it active for the child. The plain-English meaning is that you cannot drop the policy because of anger or a dispute. The consequence of canceling coverage without a court order is a contempt finding under Code of Civil Procedure § 1218, punishable by up to five days in jail per count.

Example: Maria in Los Angeles drops her son from her Kaiser plan after her ex-husband stops paying support. The judge later finds her in contempt because the support order and health-coverage order are independent. A common misconception is that “no support equals no insurance” — California law treats the two duties as separate.

Paragraph 2 — Assignment of Insurance Reimbursements

Under Family Code § 3751.5, the non-insured parent may submit claims directly to the insurer if the insured parent refuses to forward reimbursements. The form tells insurers they must honor the assignment. The consequence of an insurer ignoring the assignment is liability under ERISA § 609 for ERISA-governed plans.

Paragraph 3 — The 50/50 Default Split

Uninsured costs are split equally unless the court orders otherwise. The judge can change the ratio under Family Code § 4061(b) by applying the same income shares used in the California Guideline Child Support Calculator. A common misconception is that the higher earner always pays more — the split stays 50/50 unless someone files a motion.

Paragraph 4 — The 30-Day Notice Rule

The parent who pays a medical bill must give written notice and a copy of the bill to the other parent within a reasonable time, not to exceed 30 days from receiving the invoice. The plain-English meaning is: scan the bill and email or mail it fast. The consequence of waiting more than 30 days is that the judge may reduce or deny reimbursement under § 4063(b).

Example: David in San Diego pays $4,200 for his daughter’s braces but waits seven months to send the invoice. The court reduces his reimbursement to zero because the delay prejudiced his ex-wife’s ability to budget.

Paragraph 5 — The 30-Day Payment Rule

Once the other parent receives proof, they have 30 days to pay their share or set up a written payment plan. The consequence of refusing is a money judgment plus 10% interest under CCP § 685.010. The court can also award attorney fees under Family Code § 4063(c).

Paragraph 6 — Disputed Charges

If a parent disputes the reasonableness of a charge — for example, an out-of-network ER visit when an in-network clinic was open — they must file a Request for Order (FL-300) within 30 days of receiving the bill. Silence equals consent under § 4063(d). A common misconception is that you can simply “refuse to pay” — refusal without filing FL-300 still creates an enforceable debt.

Paragraph 7 — Required Documentation

The paying parent must provide an itemized invoice, proof of payment, and an explanation of benefits (EOB) from the insurer. Missing any of the three pieces gives the other parent a defense. Jasmine in Sacramento learned this when her contempt motion was denied because she only provided a credit-card statement, not the EOB.

Calculating Each Parent’s Share

Most disputes come from arithmetic, not malice. Use this formula when the order keeps the default 50/50 split:

[ \text{Owed Share} = \frac{(\text{Total Bill} – \text{Insurance Payment} – \text{Other Discounts})}{2} ]

When the court has set a non-equal share, replace the divisor with each parent’s percentage from the DissoMaster or guideline printout. The result is the dollar amount the non-paying parent owes within 30 days.

Worked Example: Orthodontia

Carlos in Fresno pays a $5,000 orthodontia invoice. The insurer covers $1,500. The remaining balance is $3,500. Under the default split, his ex-wife owes $1,750 within 30 days of receiving the EOB and itemized invoice. If she pays nothing, Carlos can file Form FL-490 for entry of judgment.

Worked Example: High-Deductible Plan

Aisha in Oakland has a $6,000 family deductible. Her child’s surgery costs $8,400. The insurer applies $6,000 to the deductible and pays $2,400. Aisha owes $6,000 out of pocket. Her ex owes $3,000 under the 50/50 rule. The deductible counts as an uninsured cost under Family Code § 4062(a)(2).

Worked Example: Disputed ER Visit

Brandon in Riverside takes his son to an out-of-network ER for a sprained wrist. The bill totals $3,200. His ex argues an urgent-care clinic was open and reasonable. She files FL-300 within 30 days. The court rules the charge unreasonable and reduces her share to the in-network urgent-care equivalent of $250.

The Three Most Common FL-192 Scenarios

Below are the three scenarios California family-law judges see most often, drawn from published opinions and DCSS enforcement data.

Parent’s Move	Court’s Response
Pays bill, sends invoice within 30 days, ex refuses to pay	Court enters judgment for full share plus 10% interest and attorney fees
Pays bill but waits 11 months to send invoice	Court applies § 4063(b) and may reduce or deny reimbursement
Drops child from health plan during dispute	Court holds parent in contempt under CCP § 1218 with possible jail time

Disputed Charge Type	Likely Outcome
Out-of-network ER when in-network was open	Reduced to in-network equivalent under § 4063(d)
Elective cosmetic procedure with no medical need	Denied entirely as not “necessary” under § 4062
Orthodontia recommended by licensed dentist	Approved as a mandatory add-on under § 4062(a)(2)

Documentation Provided	Enforcement Result
Itemized invoice + EOB + proof of payment	Judgment granted, fees awarded
Only a credit-card statement	Motion denied for lack of itemization
Email screenshot of bill, no EOB	Continued for further proof

Enforcement Tools When the Other Parent Refuses

If the 30-day clock runs out, you have four enforcement paths under California law. Each path has a different speed, cost, and risk profile.

Path 1 — FL-490 Money Judgment

Form FL-490 converts the unpaid share into a judgment. The plain-English meaning is that you turn the medical bill into a court-collectable debt. The consequence for the debtor is a lien on real estate, a levy on bank accounts, and 10% statutory interest. Priya in San Jose used FL-490 to collect $7,800 in unpaid orthodontia costs after her ex ignored two demand letters.

Path 2 — Wage Garnishment via FL-195

The Income Withholding for Support (FL-195) order can be amended to include unpaid medical reimbursements. Employers must comply within 10 days under CCP § 706.022. The garnishment cap is 50% of disposable earnings under 15 U.S.C. § 1673(b).

Path 3 — Contempt Under CCP § 1218

Contempt is the nuclear option. You must prove willful disobedience beyond a reasonable doubt under In re Marriage of Cryer (2011) 198 Cal.App.4th 1039. The penalty is up to five days in jail per count and a $1,000 fine, plus attorney fees. Contempt requires personal service of an Order to Show Cause (FL-410).

Path 4 — Local Child Support Agency

If your case is open with the local DCSS office, the agency can collect medical reimbursements at no cost. The agency uses license suspension, tax intercepts, and credit reporting under Family Code § 17520. The trade-off is slower processing — typically 90 to 180 days.

Federal Overlay: ERISA, ACA, and IRS Rules

California cannot override federal health-plan rules. ERISA § 609 requires plans to honor a Qualified Medical Child Support Order (QMCSO). Without a QMCSO, an employer plan can refuse to enroll the child even if the state order says otherwise.

The Affordable Care Act bars insurers from denying coverage to a child based on a pre-existing condition. The IRS Publication 502 defines which expenses qualify as “medical” — and California courts often borrow that list when deciding what counts as an uninsured cost under § 4062.

A common misconception is that orthodontia is “cosmetic.” IRS Pub. 502 expressly lists braces as a deductible medical expense, and California courts follow suit when the orthodontist provides a medical-necessity letter.

Mistakes to Avoid

Avoid these seven errors that defeat reimbursement claims more than any others.

• Waiting past 30 days to send the bill. The court can deny your claim under § 4063(b).
• Sending only a credit-card receipt. Judges require an itemized invoice plus the EOB.
• Refusing payment without filing FL-300. Silence is consent — the debt becomes enforceable automatically.
• Cancelling the child’s health insurance. This triggers contempt under CCP § 1218.
• Choosing out-of-network providers without a reason. The court will reduce the share to the in-network rate.
• Forgetting to add interest at 10%. You leave money on the table when filing FL-490.
• Not serving the other parent personally for contempt. Service by mail is invalid for FL-410 contempt proceedings.

Do’s and Don’ts

Use this checklist before sending or paying any reimbursement demand.

• Do keep a dated log of every bill, EOB, and email to prove timeliness.
• Do scan and email bills the same week you receive them to start the 30-day clock fairly.
• Do use certified mail with return receipt for any demand over $500 to lock in proof of service.
• Do check the DCSS guideline calculator before assuming a 50/50 split.
• Do request itemized statements from providers — California law gives patients that right under Health & Safety Code § 1339.585.
• Don’t mix child support arrears with medical reimbursements on the same FL-490 — file separate judgments.
• Don’t assume verbal agreements modify FL-192 — only a court order can.
• Don’t sign a stipulated waiver of FL-192 rights without a lawyer reviewing it.
• Don’t delete texts or emails about medical bills — they are admissible evidence.
• Don’t pay disputed bills before raising the dispute — payment can waive your objection.

Pros and Cons of Self-Enforcing FL-192

Many parents wonder whether to enforce FL-192 themselves or hire counsel.

• Pro — Low filing cost. FL-490 fees can be waived with a fee-waiver application.
• Pro — Fast judgment. A clean FL-490 packet can produce a judgment in 30 to 60 days.
• Pro — Statutory attorney fees. Even pro per parents may recover costs under § 4063(c).
• Pro — Automatic 10% interest accrues from the date of demand.
• Pro — DCSS support is free if your case is IV-D.
• Con — Contempt requires criminal-grade proof. Most pro per filings fail on this standard.
• Con — Service rules are strict. Mistakes in personal service can void months of work.
• Con — Document gathering is slow. EOBs from insurers can take 45–60 days.
• Con — Emotional cost is high. Litigation can deepen co-parenting conflict.
• Con — Appellate risk. A losing party can appeal under CCP § 904.1, tying up reimbursement for a year or more.

Key Court Rulings to Know

Three California cases shape how judges read FL-192 today.

In In re Marriage of Cryer (2011) 198 Cal.App.4th 1039, the Court of Appeal confirmed that willful non-payment of medical reimbursements supports contempt. The case is the leading authority on intent under CCP § 1218.

In In re Marriage of Lusby (1998) 64 Cal.App.4th 459, the court held that uninsured medical costs are “additional support” and accrue 10% statutory interest automatically once reduced to judgment.

In County of Santa Clara v. Wilson (2003) 111 Cal.App.4th 1324, the court reaffirmed that local child support agencies can collect medical add-ons in IV-D cases without a separate FL-490 if the order incorporates FL-192 by reference.

Key Entities and Their Roles

Several agencies and people influence every FL-192 case. The Judicial Council of California drafts and revises the form. The California Department of Child Support Services supervises local agencies that enforce IV-D cases. The local family-law facilitator provides free help to self-represented parents in every California county.

The California Department of Insurance handles complaints when an insurer ignores an assignment under § 3751.5. The federal Department of Labor enforces QMCSO compliance for ERISA plans. The IRS defines deductible medical expenses, which California courts use as a guidepost.

County-Specific Procedures

While FL-192 is statewide, local rules add wrinkles. Los Angeles Superior Court requires a Notice of Motion (FL-301) cover sheet for every reimbursement RFO. Orange County uses the Orange County Local Rule 705 for medical add-ons. San Diego operates a dedicated child support commissioner department under SDSC Local Rule 5.6. Alameda County offers a free Self-Help Center that pre-screens FL-490 packets.

The plain-English meaning is that filing the same FL-192 motion in different counties can produce different timelines. The consequence of ignoring local rules is rejection at the clerk’s window, which restarts your 30-day enforcement clock.

Step-By-Step Process for Filing an FL-490 Reimbursement

Follow these steps to convert an unpaid share into a money judgment.

1. Gather documents. Collect the itemized invoice, EOB, and proof of payment.
2. Send a written demand. Use email or certified mail; keep the receipt.
3. Wait 30 days. Start counting from the date the other parent received the demand.
4. Complete FL-490. Identify the case number, principal owed, and 10% interest.
5. File and serve. Pay the filing fee or submit a fee waiver via FW-001.
6. Wait for the clerk. California courts typically enter the judgment within 30 to 60 days.
7. Collect. Use FL-195 wage garnishment, a bank levy, or a real-estate lien.

Each step has its own statute of limitations and service rules. Skipping a step does not save time — it usually adds 60 to 90 days to your case.

FAQs

Do I need to sign FL-192?

No. FL-192 is a statutory notice; it requires no signature, no checkmarks, and no date. The court attaches it automatically to your child support order.

Does FL-192 apply to adult children?

No. FL-192 covers minors and disabled adult children covered by a child support order under Family Code § 3910. Adult, non-disabled children are not covered.

Can I waive my FL-192 rights in a settlement?

No. Parents cannot waive a child’s right to health-care support, although they can stipulate to a non-50/50 split with the judge’s approval under § 4061(b).

Are co-pays considered uninsured costs?

Yes. Co-pays, deductibles, and coinsurance are all uninsured costs under Family Code § 4062 and are split between the parents.

Does the 30-day clock start at the date of service or the date of treatment?

No, not the treatment date. The 30-day notice clock starts when the paying parent receives the bill from the provider or insurer.

Can I claim mileage for medical visits?

No. California courts generally do not allow mileage reimbursement under § 4062 unless the order specifically lists transportation as an add-on cost.

Is therapy a covered uninsured cost?

Yes. Mental-health treatment qualifies as a medical cost under § 4062 and IRS Pub. 502, provided a licensed provider treats the child.

Can my ex refuse to share the insurance card?

No. Family Code § 3751 requires the insured parent to give the other parent the insurance card, group number, and claim forms.

Will small-claims court hear an FL-192 dispute?

No. Family Code reimbursements must be filed in the family-law court that issued the support order, not in small claims, under CCP § 116.220.

Does interest really accrue at 10%?

Yes. Once reduced to judgment, unpaid medical reimbursements accrue 10% simple interest per year under CCP § 685.010.

Can I collect attorney fees for enforcing FL-192?

Yes. Under § 4063(c), the prevailing party may recover reasonable attorney fees and costs, even when self-represented for filing costs.

Does FL-192 apply to step-parent insurance?

Yes. If a step-parent’s plan covers the child, the same 30-day notice and reimbursement rules apply because the order, not the policyholder, controls.