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.
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.