Insurance External Review Request Log PDF
Track state DOI, HHS, or IRO external review submissions with fees, documents, and status notes.
External review requests
Narrow layout only. No validation logic. Track escalation steps.
| Request Date | Review Agency / Program | Insurance Company | Policy / Member ID | Claim Number | Reason for Review | Documents Submitted | Review Fee | Current Status / Notes | Actions |
|---|---|---|---|---|---|---|---|---|---|
Keep all external review requests in one log. Narrow width only.
🔒 MANDATORY CODEX SAFETY FOOTER (INCLUDE VERBATIM)
Non-Negotiable Guardrails
- Do not modify global layout, header, footer, ads, analytics, or shared components
- Do not import @/components/ui/select or any unverified shadcn components
- Use native HTML inputs only
- Row add/remove buttons must be plain <button>
- No date math, no parsing, no calculations
- PDF builders must return Promise<Uint8Array>
- Always create Blobs using bytesToPdfBlob(bytes) from lib/pdf/bytes.ts
- Never include null in React-PDF style arrays
- No refactors
- Tool may only break itself
Safety notes
- Processing stays in your browser. PDFs generate locally—no uploads or accounts.
- Downloads use a secure PDF blob helper (no raw array buffers or workers required).
- Review details before sending; nothing here is legal advice or a substitute for local forms.