Insurance Appeal Evidence Checklist PDF

List each document, mark whether it is included, and track sources for your appeal packet.

Appeal evidence checklist

List documents, mark if they are included, and track the source or provider.

Use the checkbox to mark items gathered for your appeal packet.

Item 1Fill out the evidence details below.

Evidence Item

Included

Checked items appear as ☑ in the PDF.

Source / Provider

Notes

Rows stay even if blank so you can print and fill by hand.

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