Use this as a private worksheet
Record what you were told about fees, costs, approval, and payment. This is not an official agency or court form.
Fee review
- ☐ Fee method: ______________________________
- ☐ State approval required?: ______________________________
- ☐ Case costs: ______________________________
- ☐ When paid: ______________________________
- ☐ Who pays costs if no recovery: ______________________________
- ☐ Written agreement received?: ______________________________
Privacy reminder
Keep sensitive medical, wage, claim-number, and employment information private. Share it only with appropriate official agencies, licensed professionals, insurers, treating providers, or other people who legitimately need it for the claim.