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Run: Form 5A Scope of Project Services Review

Form 5A Scope of Project Services Review is a compliance review form for confirming that every in-scope service and delivery mode is listed accurately for HR...

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Review Overview

Review title (required)

Review date (required)

Review period start (required)

Review period end (required)

Reviewer name (required)

Reviewer role (required)

Project and Site Information

Project name (required)

Site name (required)

Site type (required)

Service area counties

List counties or equivalent service area descriptors only if needed for the review.

In-Scope Services Review

Services reviewed (required)

Are all in-scope services listed on Form 5A? (required)

If no, describe the missing in-scope services (required)

List only the services that are missing from the current Form 5A.

Are service descriptions accurate and sufficiently specific? (required)

Modes of Delivery Review

Modes of delivery verified (required)

Are all applicable modes of delivery documented? (required)

If no, describe the missing or incorrect modes of delivery (required)

Include the service name and the specific mode of delivery that needs correction.

If telehealth is used, is it documented appropriately?

Exceptions and Changes

Are any out-of-scope items listed on Form 5A? (required)

If yes, describe the out-of-scope items (required)

Have there been changes since the last review? (required)

If yes, summarize the changes (required)

Attestation and Submission

I attest that this review accurately reflects the current Form 5A scope of project services. (required)

Yes No N/A

Is follow-up or correction needed? (required)

If yes, describe the follow-up needed (required)

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