About This Worksheet
Worksheet to create a chronological summary of all medical evidence supporting your VA disability claim.
This worksheet helps you organize and calculate the key information for medical evidence summary worksheet. Fill in each section carefully. Use the calculation areas to verify your numbers before transferring them to the official form.
How to Complete This Worksheet
- Print this worksheet or use it on screen.
- Complete each section in order.
- Use a calculator for all math. Do not estimate.
- Double-check every calculation before moving to the next section.
- Transfer final figures to your official form when complete.
- Keep this worksheet with your records.
Medical Evidence Summary Calculations
Enter your figures for medical evidence summary worksheet below. Pull numbers from official documents, not estimates.
Medical Evidence Summary Worksheet
| A. | Total billed amount for the denied service | $ ________ |
| B. | Amount your insurance would have covered | $ ________ |
| C. | Your out-of-pocket cost due to the denial | $ ________ |
| D. | Cost of getting supporting documentation (medical records, letters) | $ ________ |
| E. | Total financial impact (C + D) | $ ________ |
Your Information
Enter your details as they appear on your official documents.
As it appears on your government ID.
Today's date, MM/DD/YYYY.
From prior medical evidence summary worksheet filings. Write N/A if none.
Additional Notes
Record any other information relevant to your medical evidence summary worksheet calculations.
Verification
Before transferring figures to your official form, confirm:
- All figures are accurate and match your source documents.
- All calculations have been double-checked with a calculator.
- Names and dates match your official identification.
- Information is consistent with requirements for medical evidence summary worksheet.