Workers’ Comp Medical Evidence Log

Keep visits, treatments, bills, and denials organized so you can share a clean PDF with your attorney, adjuster, or a judge. This is not legal advice.

Claim details

Claimant name

Employer name

Insurer / TPA

Claim number (optional)

Date of injury

Body parts injured

Primary attorney (optional)

Case background / notes

Medical evidence log

List each visit, bill, or document for your claim.

Date of service

Provider

Location

Service type

Document type

Billed amount (optional)

Paid amount (optional)

Status

Notes (optional)

Add claimant info, injury date, and at least one evidence item.