Eligibility Verification Audit Checklist Form
Record review checks, assessment, and audit findings.
Audit date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewer name
*
First Name
Last Name
Audit checklist
*
Eligibility criteria were reviewed against the applicable guidelines
Supporting documentation was reviewed for completeness
Recorded decisions are consistent with the documented criteria
Exceptions or discrepancies were documented for follow-up
Overall audit rating
*
Needs improvement
1
2
3
4
Meets expectations
5
1 is Needs improvement, 5 is Meets expectations
Audit outcome
*
Meets expectations
Needs follow-up
Further review required
Audit findings and follow-up notes
Submit Audit
Should be Empty: