Treatment Gap Explanation Checklist worksheet
Use this checklist to organize insurance, cost, transportation, symptoms, provider access, and documentation.
| Item | Your notes |
|---|---|
| Use This Checklist To Organize Insurance | ____________________________ |
| Cost | ____________________________ |
| Transportation | ____________________________ |
| Symptoms | ____________________________ |
| Provider Access | ____________________________ |
| Documentation | ____________________________ |
| Provider | ____________________________ |
| Dates of treatment | ____________________________ |
| Diagnosis or condition | ____________________________ |
| Key test or finding | ____________________________ |
| Treatment tried | ____________________________ |
| Medication or side effect | ____________________________ |
Before you use this checklist
- Copy dates and instructions from the current SSA notice rather than memory.
- Keep originals and work from copies.
- Do not send Social Security numbers, bank information, or full medical files to an unverified recipient.
- Save filing confirmations and proof of any time-sensitive submission.