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.