Provider Recertification Audit Checklist Form
Complete this checklist to document provider recertification audit findings and actions. Ensure all sections are filled out accurately for a thorough review.
Provider Name
*
Provider ID or Registration Number
*
Audit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Auditor Name
*
Recertification Period
*
Please Select
1 Year
2 Years
3 Years
Other
Provider Status
*
Active
Inactive
Pending
Checklist of Required Recertification Documents/Criteria
*
Proof of current licensure
Updated insurance certificate
Recent background check
Continuing education records
Compliance training completion
Other
Compliance Observations
Corrective Actions Needed
Target Completion Date for Corrective Actions
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Final Audit Outcome
*
Recertified
Recertification Denied
Recertification Deferred
Submit Audit Checklist
Should be Empty: