Personal Info

Insurance

Denial Details

Medical Context

Goals & History

Review & Submit

Let's Get Started

We'll need your contact information to schedule your consultation

First Name *

Last Name *

Email Address *

Phone Number *

We'll use this to confirm your consultation time

State of Residence *

Insurance Details

Tell us about the insurance plan involved in this denial

Insurance Company Name *

Plan Type *

Policy Number

Found on your insurance card

Group Number

If applicable

Employer/Coverage Source (Optional)

If this is employer-based coverage

Denial Details

Information about the specific claim denial

Date of Denial *

Denial Code (if known)

Usually in the denial letter

Service/Treatment Denied *

Provider Name *

Reason Given for Denial

This helps us understand the insurer's position

Supporting Documents

Upload copies of your denial letter, EOB, and any other relevant documents. This helps us prepare for your consultation.

Denial Letter

📄

Click to upload or drag and drop PDF, JPG, or PNG (max 10MB)

Explanation of Benefits (EOB)

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Click to upload or drag and drop PDF, JPG, or PNG (max 10MB)

Medical Context

Help us understand your health situation and timeline

Condition Being Treated *

For example: 'Chronic lower back pain from herniated disc' or 'Post-surgery rehabilitation'

How long have you been dealing with this? *

How is this denial affecting you? *

Timeline & Goals

Tell us about your timeline and what you've tried so far

How urgent is this? *

Urgent — I need this treatment now

Moderate — I need it within 30 days

Planning ahead — I can wait 30+ days

Have you already appealed this denial? *

Yes

What appeals have you tried?

Include dates and outcomes if possible

What outcome are you hoping for? *

Anything else we should know?

Review Your Information

Please review your intake information before submitting. Ned will use this to prepare for your consultation. ($497/session)

Consultation Prep Sheet

Contact Information

Name

—

Phone

—

State

—

Insurance Information

Insurance Company

—

Plan Type

—

Policy #

—

Group #

—

Denial Details

Denial Date

—

Denial Code

—

Service Denied

—

Provider

—

Denial Reason

—

Medical Context

Condition

—

Duration

—

Impact

—

Timeline & Goals

Urgency

—

Previous Appeals

—

Goals

—

Documents Uploaded

Denial Letter: Not uploaded

EOB: Not uploaded

Other Documents: Not uploaded

Next Steps: After you submit, Ned will review your information within 24 hours. You'll receive an email with your scheduled consultation time and any prep materials.

✓

You're All Set!

Thank you for completing your intake form. We've received your information and will get you scheduled within 24 hours.

What Happens Next

Review: Ned will carefully review your case details and documents
Scheduling: You'll receive an email with your consultation time slot
Preparation: Any prep materials or forms will be sent before your call
Consultation: Join your 1:1 consultation with Ned Lutz to develop your appeal strategy

Schedule Your Consultation

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Calendly Scheduler

Embed your Calendly link here for direct scheduling

Questions? Email us at info@coverageunlocked.com or call (XXX) XXX-XXXX

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Let's Get Started

Insurance Details

Denial Details

Supporting Documents

Medical Context

Timeline & Goals

Review Your Information

Consultation Prep Sheet

Contact Information

Insurance Information

Denial Details

Medical Context

Timeline & Goals

Documents Uploaded

You're All Set!

What Happens Next

Schedule Your Consultation