HIPAA Special Enrollment Compliance Checklist
Use this checklist to assess and document compliance with HIPAA special enrollment requirements.
Organization Name
*
Employee Full Name
*
First Name
Last Name
Employee Department or Division
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Special Enrollment Event
*
Loss of other coverage
Marriage
Birth or adoption of a child
Divorce or legal separation
Death of spouse or dependent
Other qualifying event
Compliance Checklist: Please indicate whether the following requirements have been met for this special enrollment event.
*
Rows
Yes
No
N/A
Employee provided timely notification of event
1
2
3
Required documentation of event received
4
5
6
Special enrollment notice provided to employee
7
8
9
Coverage effective date determined correctly
10
11
12
Plan options explained to employee
13
14
15
Supporting Documentation Uploaded
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Comments or Notes (optional)
Reviewer Name
*
First Name
Last Name
Reviewer Email Address
*
example@example.com
Signature of Reviewer
*
Submit Checklist
Submit Checklist
Should be Empty: