Collateral Source Tracking Worksheet
COLLATERAL SOURCE TRACKING WORKSHEET
Case Name: [________________________________]
Case/Claim Number: [________________________________]
Date of Incident: [__/__/____]
Date Prepared: [__/__/____]
Prepared By: [________________________________]
SECTION 1: JURISDICTIONAL ANALYSIS
State/Jurisdiction: [____]
Collateral Source Rule Status:
☐ Traditional Rule (Collateral Source Benefits Not Deducted)
- Defendant cannot reduce damages by amounts paid by collateral sources
- Plaintiff may receive "double recovery"
☐ Modified Rule (Collateral Source Offset Required/Permitted)
- Damages reduced by some or all collateral source payments
- Describe modification: [________________________________]
☐ Partial Modification
- Offset required for: [________________________________]
- No offset for: [________________________________]
Applicable Statute/Rule:
[________________________________]
Key Jurisdictional Notes:
[________________________________]
[________________________________]
SECTION 2: CLAIMANT INFORMATION
Name: [________________________________]
Date of Birth: [__/__/____]
Date of Incident: [__/__/____]
SSN (last 4): XXX-XX-[____]
SECTION 3: COLLATERAL SOURCE IDENTIFICATION
A. Health Insurance Benefits
Private Health Insurance:
| Carrier Name | Policy Number | Type | Self-Funded? | Amount Paid | Subrogation Claimed |
|---|---|---|---|---|---|
| [________________________________] | [________] | ☐ PPO ☐ HMO ☐ Other | ☐ Yes ☐ No | $ [________] | $ [________] |
| [________________________________] | [________] | ☐ PPO ☐ HMO ☐ Other | ☐ Yes ☐ No | $ [________] | $ [________] |
ERISA Plan (Employer-Sponsored):
| Employer/Plan Name | Plan Type | Self-Funded? | Amount Paid | Lien Claimed |
|---|---|---|---|---|
| [________________________________] | [________] | ☐ Yes ☐ No | $ [________] | $ [________] |
Note: Self-funded ERISA plans are subject to federal preemption and typically have stronger subrogation/reimbursement rights.
B. Government Health Benefits
| Program | ID Number | Amount Paid | Lien/Subrogation |
|---|---|---|---|
| Medicare Part A | [________________] | $ [________] | $ [________] |
| Medicare Part B | [________________] | $ [________] | $ [________] |
| Medicare Part D | [________________] | $ [________] | $ [________] |
| Medicare Advantage | [________________] | $ [________] | $ [________] |
| Medicaid | [________________] | $ [________] | $ [________] |
| TRICARE/VA | [________________] | $ [________] | $ [________] |
| CHIP | [________________] | $ [________] | $ [________] |
| Indian Health Service | [________________] | $ [________] | $ [________] |
C. Auto Insurance Benefits
| Carrier | Policy Number | Coverage Type | Amount Paid | Subrogation |
|---|---|---|---|---|
| [________________] | [________] | ☐ PIP ☐ MedPay ☐ UM/UIM | $ [________] | $ [________] |
| [________________] | [________] | ☐ PIP ☐ MedPay ☐ UM/UIM | $ [________] | $ [________] |
D. Workers' Compensation
| Carrier/Administrator | Claim Number | Medical Paid | Indemnity Paid | Lien Amount |
|---|---|---|---|---|
| [________________________________] | [________] | $ [________] | $ [________] | $ [________] |
E. Disability Benefits
| Source | Type | Amount Paid | Subrogation? |
|---|---|---|---|
| [________________________________] | ☐ STD ☐ LTD | $ [________] | ☐ Yes ☐ No |
| [________________________________] | ☐ STD ☐ LTD | $ [________] | ☐ Yes ☐ No |
| Social Security Disability (SSDI) | Government | $ [________] | ☐ N/A |
| SSI | Government | $ [________] | ☐ N/A |
F. Other Collateral Sources
| Source | Type | Amount Paid | Subrogation/Offset |
|---|---|---|---|
| Sick leave/PTO (employer paid) | Employment | $ [________] | [________________] |
| Life insurance (if applicable) | Insurance | $ [________] | ☐ Usually No Offset |
| Charitable donations | Voluntary | $ [________] | ☐ Usually No Offset |
| Crowdfunding | Voluntary | $ [________] | [________________] |
| Other: [________________] | [________] | $ [________] | [________________] |
SECTION 4: COLLATERAL SOURCE SUMMARY
| Source Category | Total Paid | Subrogation/Lien Claimed | Net Collateral |
|---|---|---|---|
| Private Health Insurance | $ [________________] | $ [________________] | $ [________________] |
| ERISA Health Plan | $ [________________] | $ [________________] | $ [________________] |
| Medicare | $ [________________] | $ [________________] | $ [________________] |
| Medicaid | $ [________________] | $ [________________] | $ [________________] |
| Other Government Health | $ [________________] | $ [________________] | $ [________________] |
| Auto Insurance (PIP/MedPay) | $ [________________] | $ [________________] | $ [________________] |
| Workers' Compensation | $ [________________] | $ [________________] | $ [________________] |
| Disability Benefits | $ [________________] | $ [________________] | $ [________________] |
| Other: [________________] | $ [________________] | $ [________________] | $ [________________] |
| TOTAL COLLATERAL SOURCES | $ [________________] | $ [________________] | $ [________________] |
SECTION 5: SUBROGATION/LIEN TRACKING
A. Lien Verification Status
| Lienholder | Lien Amount Claimed | Verified? | Disputed Items | Adjusted Amount |
|---|---|---|---|---|
| [________________________________] | $ [________] | ☐ Yes ☐ No | $ [________] | $ [________] |
| [________________________________] | $ [________] | ☐ Yes ☐ No | $ [________] | $ [________] |
| [________________________________] | $ [________] | ☐ Yes ☐ No | $ [________] | $ [________] |
| [________________________________] | $ [________] | ☐ Yes ☐ No | $ [________] | $ [________] |
| [________________________________] | $ [________] | ☐ Yes ☐ No | $ [________] | $ [________] |
B. Lien Reduction Strategies Applicable
| Lienholder | Reduction Strategy | Potential Reduction |
|---|---|---|
| [________________________________] | ☐ Made Whole ☐ Common Fund ☐ Comp Fault ☐ State Law | $ [________] |
| [________________________________] | ☐ Made Whole ☐ Common Fund ☐ Comp Fault ☐ State Law | $ [________] |
| [________________________________] | ☐ Made Whole ☐ Common Fund ☐ Comp Fault ☐ State Law | $ [________] |
| [________________________________] | ☐ Made Whole ☐ Common Fund ☐ Comp Fault ☐ State Law | $ [________] |
C. Lien Correspondence Log
| Date | Lienholder | Action | Response |
|---|---|---|---|
| [__/__/____] | [________________] | [________________] | [________________] |
| [__/__/____] | [________________] | [________________] | [________________] |
| [__/__/____] | [________________] | [________________] | [________________] |
| [__/__/____] | [________________] | [________________] | [________________] |
SECTION 6: OFFSET ANALYSIS (If Applicable)
Jurisdictional Offset Rules:
Does jurisdiction require/permit collateral source offset?
☐ No offset permitted (traditional rule)
☐ Offset required for all collateral sources
☐ Offset required only for: [________________________________]
☐ Offset permitted at court's discretion
☐ Offset subject to subrogation rights consideration
Offset Calculation (If Required):
| Damage Category | Gross Damages | Collateral Source Payments | Offset Amount | Net Damages |
|---|---|---|---|---|
| Past Medical | $ [________] | $ [________] | $ [________] | $ [________] |
| Future Medical | $ [________] | N/A | N/A | $ [________] |
| Lost Wages (Past) | $ [________] | $ [________] | $ [________] | $ [________] |
| Lost Wages (Future) | $ [________] | N/A | N/A | $ [________] |
| Other Economic | $ [________] | $ [________] | $ [________] | $ [________] |
| TOTAL ECONOMIC | $ [________] | $ [________] | $ [________] | $ [________] |
Write-Off/Discount Considerations:
| Provider | Billed Amount | Insurance Paid | Write-Off | Claimable Amount |
|---|---|---|---|---|
| [________________] | $ [________] | $ [________] | $ [________] | $ [________] |
| [________________] | $ [________] | $ [________] | $ [________] | $ [________] |
| [________________] | $ [________] | $ [________] | $ [________] | $ [________] |
| [________________] | $ [________] | $ [________] | $ [________] | $ [________] |
| TOTAL | $ [________] | $ [________] | $ [________] | $ [________] |
Note: Jurisdictions differ on whether plaintiff can claim billed amount or only amount actually paid. Some states (e.g., California under Howell v. Hamilton Meats) limit recovery to amount actually paid/incurred.
SECTION 7: IMPACT ON SETTLEMENT
Settlement Value Before Collateral Source Considerations:
| Damage Element | Claimed Amount |
|---|---|
| Economic Damages | $ [________________] |
| Non-Economic Damages | $ [________________] |
| TOTAL | $ [________________] |
Adjustments for Collateral Sources:
| Adjustment | Amount |
|---|---|
| Collateral Source Offset (if applicable) | ($ [________________]) |
| Outstanding Liens/Subrogation | ($ [________________]) |
| NET TO CLIENT | $ [________________] |
Settlement Distribution Projection:
| Distribution Item | Amount |
|---|---|
| Gross Settlement | $ [________________] |
| Less: Attorney Fees ([____]%) | ($ [________________]) |
| Less: Costs | ($ [________________]) |
| Less: Liens/Subrogation | ($ [________________]) |
| NET TO CLIENT | $ [________________] |
SECTION 8: LIEN NEGOTIATION TRACKING
Negotiation Status:
| Lienholder | Original Lien | Negotiated Amount | Savings | Status |
|---|---|---|---|---|
| [________________________________] | $ [________] | $ [________] | $ [________] | ☐ Pending ☐ Agreed ☐ Disputed |
| [________________________________] | $ [________] | $ [________] | $ [________] | ☐ Pending ☐ Agreed ☐ Disputed |
| [________________________________] | $ [________] | $ [________] | $ [________] | ☐ Pending ☐ Agreed ☐ Disputed |
| [________________________________] | $ [________] | $ [________] | $ [________] | ☐ Pending ☐ Agreed ☐ Disputed |
| [________________________________] | $ [________] | $ [________] | $ [________] | ☐ Pending ☐ Agreed ☐ Disputed |
| TOTAL | $ [________] | $ [________] | $ [________] |
Lien Resolution Documentation:
| Lienholder | Resolution Date | Final Amount | Documentation |
|---|---|---|---|
| [________________________________] | [__/__/____] | $ [________] | ☐ Letter ☐ Release |
| [________________________________] | [__/__/____] | $ [________] | ☐ Letter ☐ Release |
| [________________________________] | [__/__/____] | $ [________] | ☐ Letter ☐ Release |
| [________________________________] | [__/__/____] | $ [________] | ☐ Letter ☐ Release |
SECTION 9: DOCUMENTATION CHECKLIST
Insurance/Benefits Documentation:
☐ Health insurance EOBs (all dates of service)
☐ Health insurance policy/plan documents
☐ ERISA plan summary plan description
☐ Medicare conditional payment letter
☐ Medicaid lien letter
☐ Auto insurance policy declarations
☐ PIP/MedPay payment records
☐ Workers' compensation benefit printout
☐ Disability insurance records
☐ Employer benefit statements
Lien Documentation:
☐ All lien/subrogation letters received
☐ Itemized payment records from each lienholder
☐ Correspondence with lienholders
☐ Lien negotiation notes
☐ Final lien release letters
☐ Payment receipts to lienholders
SECTION 10: NOTES AND SPECIAL CONSIDERATIONS
Pending Issues:
[________________________________]
[________________________________]
[________________________________]
Strategic Considerations:
[________________________________]
[________________________________]
[________________________________]
Future Collateral Sources to Monitor:
☐ Ongoing medical treatment payments
☐ Future disability payments
☐ Medicare Set-Aside (if applicable)
☐ Other: [________________________________]
CERTIFICATION
I certify that the collateral source information in this worksheet is accurate to the best of my knowledge based on available records. This worksheet is for settlement calculation purposes and may require updates as additional information becomes available.
Signature: ________________________________________ Date: [__/__/____]
Print Name: [________________________________]
Title: [________________________________]
SOURCES AND REFERENCES
- Harmonie Group: 50 State Collateral Source Rule Overview
- Justia: Offsetting Payments from Collateral Sources
- Dentons: The Collateral Source Rule - A Compendium of State Law
- AllLaw: How the Collateral Source Rule Affects Your Injury Case
This worksheet is for informational purposes only. Collateral source rules and subrogation rights vary significantly by state and by type of payor. Consult legal counsel regarding applicable law and strategy.
About This Template
Settlement worksheets and demand packages present a case to an insurer or opposing counsel in a way that is designed to move money. They organize the medical records, lost wages, property damage, and other evidence into a clear narrative with a specific dollar demand. Insurers and defense lawyers respond to well-prepared packages; they low-ball or ignore sloppy ones, so the quality of the paperwork directly drives the size of the settlement.
Important Notice
This template is provided for informational purposes. It is not legal advice. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Last updated: February 2026
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