How To Appeal A Workers’ Compensation Denial Without A Lawyer
How to Appeal a Workers’ Compensation Denial Without a Lawyer? It sounds daunting, right? But hey, you’re tougher than you think. Getting your workers’ comp denied sucks, but you don’t need a fancy lawyer to fight back. This guide breaks down the process step-by-step, from gathering your evidence to navigating the appeals hearing.
We’ll equip you with the knowledge and strategies to make your case, even without legal representation. Let’s get started and reclaim what’s rightfully yours.
This guide will walk you through each stage of the appeals process. We’ll cover everything from understanding your rights and gathering crucial evidence to effectively presenting your case and knowing when to seek professional help. We’ll even tackle those tricky insurance company tactics and help you decipher confusing medical jargon. By the end, you’ll feel confident and prepared to navigate the appeals process with confidence.
Understanding Your Rights After Denial
Getting your workers’ compensation claim denied is frustrating, but knowing your rights and the appeals process is crucial. This section Artikels the steps you can take to understand the denial and begin the appeal process without needing a lawyer. Remember, every state has its own specific rules, so it’s vital to check your state’s workers’ compensation laws.
Obtaining the Denial Decision and Supporting Documentation
After receiving a denial, immediately request a complete copy of the decision and all supporting documentation. This is your first step in understanding why your claim was denied and building your appeal. The denial letter itself should contain instructions on how to request this information. If it doesn’t, contact the insurance company or the workers’ compensation board directly.
Be persistent and keep records of all your communication. You might need to send a formal written request via certified mail to ensure proof of delivery and receipt. Thoroughly review the decision and documentation; look for inconsistencies, errors in fact, or missing information that could support your appeal.
Appeal Timeframes
Each state sets a strict deadline for filing an appeal. These deadlines are usually short, often ranging from 10 to 30 days from the date of the denial decision. Missing this deadline can result in the dismissal of your appeal. Therefore, immediately upon receiving the denial, note the date and begin the appeal process without delay. It’s wise to contact the workers’ compensation agency or board in your state to confirm the exact deadline and any specific requirements for filing an appeal.
Failure to meet this deadline is a common reason for appeal denials, so careful record-keeping is essential.
Appeals Processes
The appeals process varies significantly by state. Some states have a multi-stage process, involving an initial hearing before an administrative law judge, followed by potential appeals to a state appeals board or even the state’s courts. Other states may have a simpler system. Your state’s workers’ compensation website will typically Artikel the steps involved, including forms to use and instructions on how to file.
In some states, a hearing might involve presenting evidence and testimony. In others, the appeal might be based solely on the written documents submitted. Understanding your state’s specific procedures is paramount to a successful appeal. For instance, some states may require you to attend a mandatory mediation session before proceeding to a formal hearing. Researching your state’s specific rules is essential for preparing a strong appeal.
Gathering Evidence to Support Your Claim
Successfully appealing a denied workers’ compensation claim hinges on presenting a strong case backed by solid evidence. This means meticulously collecting and organizing all relevant documentation to paint a clear picture of your injury, its impact on your ability to work, and the employer’s role (or lack thereof) in preventing it. The more comprehensive your evidence, the better your chances of a successful appeal.
Building your case requires a strategic approach to evidence gathering. You need to think like a detective, systematically collecting all pieces of the puzzle to create a cohesive narrative. This includes not only medical records but also details about the accident itself and its consequences on your life. Remember, you are presenting your case to a board or judge who may not be familiar with your situation, so clarity and completeness are key.
Essential Documents for a Workers’ Compensation Appeal
Compiling the right documents is crucial. Think of this checklist as your roadmap to a successful appeal. Missing even one key piece of evidence could weaken your case significantly. Make copies of everything, and keep your originals in a safe place.
- Medical Records: All doctor’s notes, test results (X-rays, MRIs, blood tests), diagnoses, treatment plans, and bills related to your injury. This is arguably the most important type of evidence.
- Witness Statements: Written accounts from anyone who witnessed your accident or injury, including coworkers, supervisors, or even bystanders. Include their contact information.
- Employment Records: Your employment contract, pay stubs, job description, and any documentation showing your work history and the circumstances surrounding your injury. This might include safety reports or incident reports.
- Photographs and Videos: Visual evidence of the accident scene, your injuries, or any related conditions. These can be incredibly powerful in supporting your claim.
- Police Reports: If law enforcement was involved in the incident, obtain a copy of the police report.
Organizing Evidence into a Compelling Narrative
Simply gathering documents isn’t enough; you need to organize them into a clear and persuasive story. Think of it like writing a brief: you need to present your case in a logical, chronological order. Start with the accident, detailing the events leading up to it, the incident itself, and the immediate aftermath. Then, follow the progression of your injury through treatment, highlighting any setbacks or complications.
Finally, explain how the injury affects your ability to work and your overall quality of life.
Types of Evidence and Their Relative Importance
Different types of evidence carry varying weight in a workers’ compensation appeal. Medical records, for instance, are generally considered the most crucial. However, a combination of evidence types strengthens your case considerably.
Type of Evidence | Importance | Example | Supporting Documentation |
---|---|---|---|
Medical Records | High | Doctor’s diagnosis of a herniated disc resulting from lifting heavy boxes at work. | Physician’s notes, MRI results, treatment plans |
Witness Statements | Medium | Coworker’s statement confirming the unsafe working conditions that led to the accident. | Written statement with contact information |
Employment Records | Medium | Job description detailing the physical demands of the job and demonstrating that the injury was work-related. | Job description, employment contract |
Photographs/Videos | Low to Medium | Pictures of the slippery floor that caused a fall. | Digital images or video files with timestamps |
Completing the Appeal Form and Filing

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Successfully navigating the workers’ compensation appeals process often hinges on accurately and completely filling out the appeal form. This seemingly straightforward step can be surprisingly complex, so careful attention to detail is crucial. Failing to do so can significantly delay or even jeopardize your claim.The appeal form itself varies depending on your state. However, most forms will request similar information.
Below is a sample form with annotations to illustrate the common sections.
Sample Appeal Form with Annotations
Imagine a form with several sections. Each section is labeled clearly, such as “Applicant Information,” “Employer Information,” “Date of Injury,” “Description of Injury,” “Reason for Appeal,” “Medical Evidence Submitted,” and “Signature and Date.”
Applicant Information: This section requires your full legal name, address, phone number, and social security number. Accuracy is paramount; any discrepancies can cause delays.
Employer Information: You’ll need to provide the employer’s legal name, address, and contact information. Double-check this information against your employment records.
Date of Injury and Description of Injury: Clearly state the date of your injury and provide a detailed description of what happened. Be precise and avoid ambiguity. For example, instead of “hurt my back,” write “sustained a lower back strain while lifting a heavy box weighing approximately 50 pounds.”
Reason for Appeal: This is arguably the most critical section. Clearly and concisely explain why you are appealing the denial. Refer to specific points of disagreement with the initial decision. For example, if the denial is based on a claim that your injury wasn’t work-related, provide evidence supporting your contention that it was.
Medical Evidence Submitted: List all medical documents, such as doctor’s notes, test results, and therapy records, that you are submitting as evidence. Be specific – for example, instead of writing “doctor’s notes,” write “Dr. Smith’s report dated October 26, 2023, detailing diagnosis of carpal tunnel syndrome.”
Signature and Date: Sign and date the form. This signifies your understanding and agreement with the information provided.
Properly Filling Out and Submitting the Appeal Form, How to Appeal a Workers’ Compensation Denial Without a Lawyer
Before submitting, thoroughly review the completed form for accuracy and completeness. Ensure all sections are filled out and all necessary supporting documentation is attached. Make copies of everything for your records. The form should be submitted to the appropriate state workers’ compensation agency, usually by mail or online, according to their specific instructions. Check their website for the exact address and any specific requirements, such as whether electronic submissions are accepted.
Always keep a copy of the submission confirmation.
Consequences of Filing an Incomplete or Inaccurate Appeal
Submitting an incomplete or inaccurate appeal can result in significant delays. The agency may reject your appeal outright, requiring you to resubmit it, potentially missing deadlines. An inaccurate appeal could weaken your case and make it harder to prove your claim. In the worst-case scenario, your appeal might be denied, leaving you without the benefits you deserve. Remember, accuracy and completeness are crucial for a successful appeal.
Navigating the Appeals Process
Appealing a denied workers’ compensation claim can feel overwhelming, but understanding the process can significantly improve your chances of success. The appeals process varies by state, so it’s crucial to consult your state’s specific workers’ compensation laws and regulations. Generally, however, the process involves several key steps.The typical workers’ compensation appeals process follows a structured path, progressing through administrative levels before potentially reaching the courts.
Each step requires careful attention to deadlines and specific procedural rules. Failure to adhere to these requirements can jeopardize your appeal.
Appeal Stages
The appeals process usually begins with an initial appeal to an administrative agency, often a state workers’ compensation board or commission. This initial appeal involves submitting a formal appeal form, along with all supporting documentation. The agency will then review the evidence, potentially holding a hearing where you can present your case and cross-examine witnesses. After reviewing the evidence and hearing testimony, the agency will issue a decision.
If you disagree with the agency’s decision, you can usually appeal to a higher administrative body, such as a state appeals court or a higher level within the workers’ compensation system. From there, the possibility of a judicial appeal to a state court may exist, depending on the specifics of your state’s legal system and the outcome of prior appeals.
The exact number of appeals levels will vary based on your location.
Methods of Presenting Your Case
There are several ways to present your case during the appeals process. You can choose to represent yourself, which allows for personal control but requires a thorough understanding of the legal process and the ability to effectively present your case. Alternatively, you can hire an attorney, who can navigate the complexities of the legal system and advocate for your rights.
A third option is to utilize the services of a paralegal or other legal assistant who can assist with the preparation and filing of paperwork, but cannot provide legal advice. The method you choose will depend on your comfort level with legal procedures, your budget, and the complexity of your case. A simpler case may be successfully handled without an attorney, while a complex case with multiple medical opinions and disputed facts may benefit significantly from professional legal representation.
Potential Outcomes of a Workers’ Compensation Appeal
The outcome of a workers’ compensation appeal can vary greatly. A successful appeal could result in the approval of your claim, leading to the payment of benefits such as medical expenses, lost wages, and potentially permanent disability payments. Conversely, an unsuccessful appeal could lead to the denial of your claim, leaving you without any compensation for your work-related injury.
In some cases, a partial approval might occur, where only certain aspects of your claim are approved. For example, medical expenses might be covered, but lost wages might be denied. The outcome often depends on the strength of your evidence, the clarity of your presentation, and the specific legal precedents and interpretations in your jurisdiction. It’s crucial to be aware that an appeal does not guarantee a favorable outcome; however, it provides an opportunity to present your case and challenge the initial denial.
Representing Yourself Effectively

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Successfully navigating a workers’ compensation appeal without legal counsel requires careful preparation and a clear understanding of the process. This involves not only compiling strong evidence but also presenting your case persuasively to the appeals board. Remember, you are advocating for yourself, and a well-organized, confident presentation can significantly impact the outcome.Preparing for and participating in a hearing without a lawyer demands a proactive approach.
You need to thoroughly understand the details of your case, anticipate potential questions from the board, and practice articulating your points clearly and concisely. This preparation will boost your confidence and allow you to present a compelling narrative of your injury and its impact on your life.
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This understanding can help you strategize your own appeal process for that workers’ comp denial, ensuring you present the most compelling evidence possible.
Preparing for the Hearing
Effective preparation is crucial for a successful self-representation. This includes organizing all your documentation – medical records, witness statements, employment records, and the denial letter – into a chronological and easily accessible format. Practice summarizing your case concisely, highlighting key events and focusing on the evidence that supports your claim. Consider creating a visual aid, such as a timeline of events, to help the board understand the sequence of your injury, treatment, and the denial.
Rehearse your testimony beforehand, focusing on clarity and accuracy. Knowing your case inside and out will project confidence and credibility.
Strategies for Effective Communication
Communicating your case effectively hinges on clarity, conciseness, and a calm, professional demeanor. Speak clearly and directly, avoiding jargon or overly technical language. Maintain eye contact with the board members and answer their questions honestly and completely. If you don’t understand a question, ask for clarification. It’s perfectly acceptable to take a moment to collect your thoughts before responding.
Remember to emphasize the impact of your injury on your ability to work and your overall well-being, painting a clear picture of your daily struggles and limitations. This personal touch helps humanize your case and connect with the board on an emotional level.
Examples of Strong and Weak Arguments
A strong argument in a workers’ compensation appeal centers on clear evidence directly linking your injury to your work. For example, a strong argument might involve a detailed medical report from a physician directly attributing a back injury to repetitive lifting at work, corroborated by witness statements from coworkers and a documented history of reporting the pain to your supervisor.
Conversely, a weak argument might consist of vague claims unsupported by medical evidence, inconsistent statements, or a lack of documentation. For instance, claiming a back injury without medical documentation or a clear connection to work activities would be a weak argument. Another weak argument could be relying solely on hearsay or unsubstantiated claims from friends or family without any verifiable evidence.
Strong arguments rely on objective evidence and a clear, concise narrative.
Understanding Medical Terminology and Documentation
Navigating the workers’ compensation appeals process often requires deciphering medical jargon and documentation. Understanding medical terminology and how to interpret reports is crucial for building a strong case, even without legal representation. This section will equip you with the knowledge to effectively analyze your medical records and identify any inconsistencies that may support your appeal.Successfully appealing a denied workers’ compensation claim hinges on effectively presenting your medical evidence.
This means understanding the language used by doctors and other healthcare providers. Being able to interpret medical reports, identify missing information, and present a clear picture of your injuries and treatment is vital to a successful appeal. This section provides guidance on how to do just that.
Common Medical Terms and Abbreviations
Medical reports frequently use abbreviations and terminology that can be confusing. Familiarizing yourself with common terms will greatly assist in understanding your medical records. The following list provides examples of frequently encountered terms and abbreviations.
- ROM: Range of Motion – This refers to the extent of movement of a joint.
- Dx: Diagnosis – The identification of a disease or condition.
- Tx: Treatment – The medical care given to a patient.
- MRI: Magnetic Resonance Imaging – A medical imaging technique using a magnetic field and radio waves.
- CT: Computed Tomography – A medical imaging technique using X-rays to create cross-sectional images.
- PT: Physical Therapy – Treatment to restore, maintain, and promote overall fitness and health.
- OTC: Over-the-Counter – Medications available without a prescription.
- Rx: Prescription – A medication requiring a doctor’s order.
- WPI: Whole Person Impairment – A rating of the overall impact of an injury on a person’s ability to function.
- RSD/CRPS: Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome – A chronic pain condition often following an injury.
Interpreting Medical Reports and Identifying Inconsistencies
Medical reports can be lengthy and complex. To effectively interpret them, focus on key elements such as the diagnosis, treatment plan, prognosis, and any limitations on work activities. Look for inconsistencies between different reports or between the medical findings and the employer’s account of the injury. For example, if one report indicates a significant limitation on lifting, but another report doesn’t mention it, this discrepancy should be highlighted.
Also note any missing information, such as a lack of objective findings to support subjective complaints of pain. This might indicate a need for further medical evaluation.
Glossary of Frequently Used Medical Terms in Workers’ Compensation Cases
Understanding medical terminology is paramount to a successful appeal. This glossary provides definitions for terms frequently encountered in workers’ compensation cases.
- Acute: A condition with a sudden onset and relatively short duration.
- Chronic: A condition persisting for a long time or constantly recurring.
- Comorbidity: The presence of one or more additional diseases or disorders co-occurring with a primary disease or disorder.
- Etiology: The cause or origin of a disease or condition.
- Prognosis: The likely course of a disease or ailment.
- Sequelae: A condition that is the consequence of a previous disease or injury.
- Subjective: Based on personal feelings, opinions, or interpretations; not directly observable.
- Objective: Based on factual observation, independent of personal feelings or opinions.
Dealing with Insurance Company Tactics: How To Appeal A Workers’ Compensation Denial Without A Lawyer
Insurance companies, while legally obligated to process workers’ compensation claims fairly, sometimes employ tactics that can delay or even deny legitimate claims. Understanding these tactics and how to counter them is crucial to a successful appeal. This section will Artikel common strategies used by insurers and provide effective responses.
Insurance companies operate under a business model that prioritizes minimizing payouts. This often leads to practices that may seem adversarial to claimants. It’s important to remember that this is a common occurrence, and you are not alone in facing these challenges. By staying informed and prepared, you can significantly increase your chances of a favorable outcome.
Common Insurance Company Tactics
Insurance companies utilize various methods to minimize payouts, often focusing on delaying the process or questioning the validity of the claim. These tactics can include aggressively questioning the nature and extent of your injuries, demanding extensive documentation, delaying or denying medical treatment, and employing aggressive negotiation tactics. For example, they might request multiple medical evaluations from doctors of their choosing, even if your own physician has already provided a thorough assessment.
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They may also try to minimize the impact of your injury on your ability to work, suggesting alternative employment options that may not be realistic or feasible given your limitations.
Countering Insurance Company Tactics
Effectively countering these tactics requires proactive and meticulous record-keeping and a firm understanding of your rights. This involves responding promptly and thoroughly to all requests for information, while simultaneously maintaining a detailed record of every communication, including emails, letters, and phone calls. If you are unsure about any request, consult with an experienced workers’ compensation advocate or legal aid organization before responding.
Don’t hesitate to seek clarification if something is unclear. Keep copies of all documents and maintain a chronological log of your interactions. This detailed record serves as crucial evidence should the matter proceed to appeal.
Maintaining Detailed Records
The importance of meticulous record-keeping cannot be overstated. Every interaction, no matter how seemingly insignificant, should be documented. This includes dates, times, names of individuals contacted, and a summary of the conversation or correspondence. Keep copies of all medical records, doctor’s notes, and any correspondence with the insurance company. This documentation will be invaluable during the appeals process, providing concrete evidence to support your claim and refute any inaccurate or misleading statements made by the insurance company.
Consider using a dedicated notebook or digital system to organize your records systematically. This organized approach will help you efficiently present your case if an appeal is necessary. For example, a detailed log showing consistent requests for information followed by delayed responses from the insurance company strengthens your case significantly.
Knowing When to Seek Professional Help

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Navigating the workers’ compensation appeals process can be complex and challenging, even when you’re representing yourself. While many individuals successfully appeal their denials without legal representation, understanding when professional help becomes crucial is essential to protecting your rights and maximizing your chances of a favorable outcome. There are certain situations where seeking legal counsel is not just beneficial, but highly recommended.The decision of whether to hire a lawyer often hinges on the complexity of your case and your personal comfort level with legal procedures.
A lawyer brings expertise in interpreting legal jargon, navigating bureaucratic processes, and presenting a strong case before the appeals board. However, legal representation comes with costs and potential drawbacks, making it important to weigh the pros and cons carefully.
Circumstances Warranting Legal Counsel
Several factors can significantly increase the likelihood that you’ll benefit from legal representation. Cases involving serious injuries, significant medical expenses, or complex legal issues are prime examples. If your claim involves a pre-existing condition, multiple injuries, or disputes over the extent of your disability, an attorney’s expertise in presenting medical evidence and legal arguments becomes invaluable. Similarly, if the insurance company is employing aggressive or questionable tactics, legal counsel can provide a crucial counterbalance.
A lawyer can help you understand your rights and ensure the insurance company adheres to legal regulations and ethical practices. Finally, if you feel overwhelmed by the process or are unsure how to proceed, a lawyer can provide much-needed guidance and support.
Resources for Affordable or Pro Bono Legal Assistance
Finding affordable or free legal assistance can be challenging, but resources are available. Many legal aid organizations offer pro bono or low-cost services to individuals who meet specific income requirements. You can start your search by contacting your state bar association’s lawyer referral service. They can provide you with a list of attorneys who handle workers’ compensation cases and may offer reduced fees or pro bono services based on your financial situation.
Additionally, many non-profit organizations specialize in assisting injured workers with their compensation claims. These organizations can provide legal advice, representation, or referrals to qualified attorneys. Check online resources and local community centers for listings of such organizations in your area. Remember to thoroughly research any organization before engaging their services.
Benefits and Drawbacks of Hiring a Lawyer
Hiring a lawyer offers several potential benefits. Experienced attorneys possess in-depth knowledge of workers’ compensation laws and procedures, enabling them to effectively navigate the complex appeals process. They can also expertly handle all aspects of your case, from gathering evidence to presenting arguments before the appeals board, freeing you to focus on your recovery. Moreover, a lawyer’s presence can often lead to a more favorable settlement or award from the insurance company, as they bring a level of authority and expertise that an individual may lack.
However, hiring a lawyer comes with financial costs, which can be significant depending on the attorney’s fees and the length of the appeal process. It’s also important to consider that even with legal representation, there’s no guarantee of success. The outcome of your case will still depend on the specifics of your situation and the evidence presented.
State-Specific Information and Resources
Navigating the workers’ compensation appeals process can feel like traversing a maze, and understanding the specific rules and resources in your state is crucial for success. Each state has its own unique workers’ compensation laws, agencies, and appeals procedures. Failing to understand these nuances can significantly impact your chances of a successful appeal. This section provides a guide to finding and utilizing state-specific information to strengthen your case.State workers’ compensation systems vary significantly in their regulations, procedures, and available resources.
Understanding these variations is key to effectively appealing a denial. Some states have more streamlined processes than others, while others may have more stringent requirements for evidence or specific forms. This section will help you locate the necessary information to navigate your state’s specific system.
State Workers’ Compensation Agency Websites and Contact Information
Finding the right contact information for your state’s workers’ compensation agency is the first step. The following table provides a starting point, though it’s crucial to verify this information through independent research as contact details can change. Always double-check the information on the official state government website. Because this information is subject to change, it is not exhaustive and should be used as a starting point for your research.
State | Agency Name | Website | Phone Number (Example – Verify!) |
---|---|---|---|
Alabama | Alabama Department of Labor | (Example: www.alabamadepartmentlabor.gov – Verify!) | (Example: 1-800-555-1212 – Verify!) |
Alaska | Alaska Workers’ Compensation Board | (Example: www.alaskaworkerscomp.gov – Verify!) | (Example: 1-800-555-1213 – Verify!) |
Arizona | Industrial Commission of Arizona | (Example: www.azica.gov – Verify!) | (Example: 1-800-555-1214 – Verify!) |
Arkansas | Arkansas Workers’ Compensation Commission | (Example: www.arkansasworkerscomp.gov – Verify!) | (Example: 1-800-555-1215 – Verify!) |
Locating State-Specific Regulations and Appeal Procedures
Once you’ve identified your state’s workers’ compensation agency, navigating their website is key to finding the specific regulations and appeal procedures. These websites usually contain detailed information about the appeals process, including deadlines, required forms, and the necessary evidence to support your claim. Look for sections titled “Appeals,” “Contested Claims,” or similar terminology.
Many state agencies also offer downloadable guides and FAQs to assist claimants in navigating the appeals process.
Variations in State Appeal Processes
State appeal processes vary widely. Some states utilize a multi-step process involving administrative hearings and judicial review, while others might have a more simplified system. Timeframes for appeals also differ significantly, ranging from a few weeks to several months. Some states allow for informal mediation before a formal appeal, while others proceed directly to a formal hearing.
The specific requirements for evidence and documentation also vary. For example, one state might require detailed medical records, while another might prioritize witness testimony. Understanding these variations is critical for preparing a strong and timely appeal.
Summary
So, you got denied workers’ comp, but don’t sweat it. You now have the tools to fight back. Remember, meticulous preparation, a clear presentation of your case, and a solid understanding of the process are your strongest weapons. While a lawyer can definitely help, you absolutely have the power to handle this yourself. Armed with this knowledge, you can confidently navigate the appeals process and hopefully get the compensation you deserve.
Good luck, and remember to stay organized and persistent!
FAQ Section
What if I miss the deadline to file an appeal?
Unfortunately, missing the deadline usually means your appeal will be dismissed. It’s crucial to understand your state’s specific timeframe.
Can I appeal more than once?
The number of appeals allowed varies by state. Some states have a single appeal, while others allow multiple levels of review. Check your state’s regulations.
What if the insurance company isn’t cooperating?
Document every interaction (emails, letters, phone calls). This documentation is crucial evidence if things get contentious. Consider contacting your state’s workers’ compensation agency for assistance.
Where can I find free legal aid?
Many legal aid organizations offer free or low-cost assistance. You can also search online for “pro bono legal services” in your area.