Use this as a private worksheet
Use this list to identify terms that deserve clarification before signing. This is not an official agency or court form.
Check carefully
- ☐ Future medical closure: ______________________________
- ☐ Broad release language: ______________________________
- ☐ Unresolved surgery/treatment: ______________________________
- ☐ Liens/offsets: ______________________________
- ☐ Resignation or employment terms: ______________________________
- ☐ Unclear payment schedule: ______________________________
Ask
- ☐ What remains open?: ______________________________
- ☐ What is permanently released?: ______________________________
- ☐ What approval is required?: ______________________________
- ☐ What is the net amount after fees/costs/liens?: ______________________________
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.