Client Record Review Form

CLIENT RECORD REVIEW FORM

RECITALS

WHEREAS, Client Name: engages Reviewer to perform a review of specified client records for the purposes described in this form; and

WHEREAS, Reviewer agrees to conduct an objective, documented review and to prepare findings and recommendations in accordance with the Scope of Work and Payment Terms set forth below.

PARTIES AND IDENTIFICATION

Date of Records to Be Reviewed:

SCOPE OF WORK

Reviewer shall perform the following services in a manner consistent with generally accepted professional standards and applicable law. Services include document collection verification, completeness assessment, accuracy checks, redaction review if required, and preparation of a written findings report.

RECORDS REVIEW CHECKLIST

Please indicate which categories of records were reviewed. Check all that apply:

Intake Forms

Consent / Authorization Forms

Progress Notes / Case Notes

Treatment Plans / Assessments

Billing / Claims Records

Correspondence / Communications

Other:

FINDINGS

Provide a concise but substantive summary of material findings, discrepancies, omissions, or compliance issues identified during the review. Include references to specific documents, dates, and pages as necessary.

RECOMMENDATIONS

State recommended corrective actions, record retention steps, training needs, or further investigation required to address the findings.

ATTACHMENTS AND EXHIBITS

List and attach copies of any documents relied upon, including exhibit labels and pages. Number of pages attached:

PAYMENT TERMS

Compensation payable to Reviewer for the Scope of Work shall be as set forth below.

Late Fee for overdue payments:

TERM AND TERMINATION

This engagement shall commence on Start Date: and shall terminate on End Date: unless earlier terminated as provided below.

Either party may terminate this engagement for convenience upon Notice Period: days' written notice. Termination for cause may occur upon material breach not cured within thirty (30) days of written notice.

Upon termination, Reviewer shall deliver all completed work and any interim reports; Client shall pay for work performed through the effective date of termination in accordance with Payment Terms.

CONFIDENTIALITY

Reviewer shall treat all information obtained from Client as confidential and shall not disclose such information except as required by law or with Client's prior written consent. Reviewer shall implement and maintain reasonable safeguards to protect confidential information, including any personal or sensitive data. Any disclosures required by law shall be promptly communicated to Client to the extent permitted.

GOVERNING LAW

This Agreement and all disputes arising out of or related to this engagement shall be governed by and construed in accordance with the laws of the State of: without regard to its conflicts of law principles.

ENTIRE AGREEMENT

This form, together with any attached exhibits or written statements of scope and fee accepted by both parties, constitutes the entire agreement between Client and Reviewer with respect to the subject matter hereof and supersedes all prior agreements, understandings, negotiations and discussions, whether oral or written. Any amendment must be in writing and signed by both parties.

CERTIFICATION AND ATTESTATION

By signing below, the undersigned individuals represent and warrant that they are authorized to execute this form on behalf of the respective parties; that the information provided in this form is, to the best of their knowledge, complete and accurate; and that they accept the Scope of Work, Payment Terms and other contractual provisions set forth herein.

I certify that I have performed the review in accordance with applicable professional standards and have documented my findings in the attached report.

Sign Now