DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16011 (07/08)
STATE OF WISCONSIN
QUALITY ASSURANCE (QA) SAMPLE CHECKLIST
This form must be completed by the local agency and attached to the case record prior to submitting the record for Quality Assurance (QA) review. Add case comments to the case file after you receive notice of the QA sample pull to explain any budgeting or eligibility issues on this case. They may help the QA reviewer understand and agree with any unusual circumstances. A QA reviewer may be contacting you in the near future to discuss the case details. Case Name Has the case been referred for fraud investigation? Yes in progress notes in the case record? Yes No Case Number No If "Yes", is a copy of the referral or work
Is documentation and verification in the case record completed for the most current review or change in the following areas?
Yes Yes Yes Yes Yes Yes Yes No No No No No No No NA NA NA NA NA NA NA
Items To Check
Household Composition Earned income (i.e. AFEI or CMCC, 4.3, 2.15, averaged, etc.) Unearned Income Shelter Expense Child Care Expense KIDS checked for child support paid out or received by household Food Stamp Six-Month Report (SMRF)
If "No" was checked above, explain what was used to determine eligibility.
If a change has been reported, is the verification: Explain: (Include the dates)
SIGNATURE - person completing this form Title
Date Signed Telephone Number ( )