Client Ineligibility Form

Client Ineligibility Form

This Client Ineligibility Form documents the determination that the party identified as Client is ineligible to receive specified services from the Service Provider set forth below, and memorializes any resulting obligations, appeal rights, and administrative terms.

Parties and File

Service Provider:

Client Name:

File or Reference Number:    Evaluation Date:

WHEREAS

WHEREAS, the Service Provider performs eligibility assessments to determine whether individuals or entities meet criteria required to receive specified services; and

WHEREAS, an assessment was completed for the Client referenced above and the Service Provider has determined, based on the assessment, supporting documentation, and applicable policies, that the Client is ineligible to receive the requested services; and

WHEREAS, the parties desire to document the reasons for ineligibility, any financial or administrative obligations that survive the determination, the Client's right to appeal, and related contractual provisions.

Determination of Ineligibility

Determination made by: on .

Primary reason(s) for ineligibility (check all that apply):

Insufficient or missing documentation
Financial ineligibility or outstanding balance
Conflict of interest, legal prohibition, or disqualification
Requested service falls outside scope of provider capabilities
Other (describe below)

Scope of Work (If applicable)

Services proposed but not to be provided as a result of this determination:

Payment Terms and Financial Obligations

Outstanding balance owed by Client (if any): $

Late fee and interest: A late fee and/or interest shall accrue on any unpaid amount at a rate of per month, compounded monthly, or the maximum permitted by applicable law, whichever is less.

Term and Termination

This Form and any related obligations are effective as of the Effective Date below. Start Date: End Date (if applicable):

Either party may terminate any prospective agreement or administrative relationship related to this determination by giving written notice to the other party days in advance, except that termination shall not relieve the Client of any accrued payment obligations described above.

Confidentiality

Both parties acknowledge that information exchanged in connection with the assessment and this determination may constitute confidential business or personal information. Each party shall maintain the confidentiality of such information and shall not disclose it except (a) as required by law, (b) to its legal or financial advisors under a duty of confidentiality, or (c) with the express written consent of the other party. This obligation shall survive termination of this Form.

Client acknowledges receipt of confidential materials: Yes

Appeals and Administrative Review

The Client may request an administrative review of this determination by submitting a written appeal to the Service Provider within days of the determination date. To initiate an appeal, check below and describe basis for appeal.

Client requests an appeal

Governing Law

This Form shall be governed by and construed in accordance with the laws of the state of without regard to its conflict of laws principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that state for any dispute arising from this Form.

Entire Agreement and Severability

This Form, together with any attachments expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior written or oral agreements. If any provision of this Form is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Acknowledgment and Certification

By signing below, the undersigned certify that they are authorized to bind the respective party, that they have reviewed and understand this Client Ineligibility Form, and that the information provided herein is true and correct to the best of their knowledge.

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