Use this as a private worksheet
Read the written denial line by line before building the response. This is not an official agency or court form.
Notice details
- ☐ Date on notice: ______________________________
- ☐ Date received: ______________________________
- ☐ Claim number: ______________________________
- ☐ Sender: ______________________________
Reason stated
- ☐ Coverage/employment: ______________________________
- ☐ Work-related causation: ______________________________
- ☐ Notice/timing: ______________________________
- ☐ Medical evidence: ______________________________
- ☐ Procedure/other: ______________________________
Evidence to compare
- ☐ Injury report: ______________________________
- ☐ Medical record: ______________________________
- ☐ Wage/employment record: ______________________________
- ☐ Official appeal instructions: ______________________________
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.
Use the worksheet with the source records
- Enter dates from the notice, medical record, payment record, or message instead of memory.
- Leave an item blank when it is unknown; do not guess to complete the page.
- Keep a private copy and update it after a new notice, appointment, payment, or work-status change.
- Bring the worksheet and the supporting documents to an agency call or lawyer consultation.