Page 59 - HarborLight CU 2014-15 SPD

Record of Completed QMCSO Procedures
(QMCSO Procedures Attachment #2)

 Initial Response to Receipt of Order

Employee’s Name:
Social Security Number:
Date Order/Notice Received:
Date Acknowledgement Sent:

Coverage employee currently enrolled in: Medical Dental Vision

None Social
Security #
Alternate Recipient(s):

Name Date of Address
Birth

 Assessment of Order (attach completed checklist)
Date checklist completed:
Checklist completed by:

IS LEGAL COUNSEL’S REVIEW NECESSARY? YES NO

Date of legal review:
Reviewed by:

No Legal Review:
DETERMINATION

Valid QMCSO
Not Valid QMCSO
(reasons to be noted on checklist)

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