Local Agency Review Tool Clinic Site Review Ineligible/Terminated/Suspended Files

Agency: Choose an item. Reviewer: Click here to enter text.

Date: Click here to enter a date. Clinic: Click here to enter text.
Family (Client) No: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Category: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item.
Termination Reason: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Accurate Determination of Ineligibility: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Timely Notice of Ineligibility provided and on file (15 days): / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Appropriately assigned benefits provided from date of termination if applicable (i.e one month, prorated package etc.): / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Comments: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /

Date: Click here to enter a date. Clinic: Click here to enter text.

Family (Client) No: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Category: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item.
Termination Reason: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Accurate Determination of Ineligibility: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Timely Notice of Ineligibility provided and on file (15 days): / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Appropriately assigned benefits provided from date of termination if applicable (i.e one month, prorated package etc.): / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Comments: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Date: Click here to enter a date. Clinic: Click here to enter text.
Family (Client) No: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Category: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item.
Termination Reason: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Accurate Determination of Ineligibility: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Timely Notice of Ineligibility provided and on file (15 days): / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Appropriately assigned benefits provided from date of termination if applicable (i.e one month, prorated package etc.): / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Comments: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Date: Click here to enter a date. Clinic: Click here to enter text.
Family (Client) No: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Category: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item.
Termination Reason: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Accurate Determination of Ineligibility: / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Timely Notice of Ineligibility provided and on file (15 days): / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Appropriately assigned benefits provided from date of termination if applicable (i.e one month, prorated package etc.): / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. / Choose an item. /
Comments: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /

Electronically Signed: Click here to enter text. Date: Click here to enter a date.

Revised 3/15