Loading...
compliance

Sliding Fee Discount Program Triennial Evaluation Form

Use this Sliding Fee Discount Program Triennial Evaluation Form to review your discount scale, pay class data, patient feedback, and corrective actions every three years. It gives you a clear record of findings, approvals, and follow-up items in one place.

See it in MangoApps Get Started

Trusted by frontline teams 15 years of frontline software

Built for: Community Health Centers · Primary Care Clinics · Behavioral Health · Nonprofit Healthcare

Overview

This Sliding Fee Discount Program Triennial Evaluation Form is a structured workplace form for reviewing how a discount program is operating over a defined three-year period. It captures the review dates, reviewer details, program version, discount scale used, pay class data, patient input, identified gaps, corrective actions, and final approval so the organization has one clear record of the evaluation.

Use it when you need to show that the program was reviewed on schedule, that eligibility and pay class decisions were checked against source data, and that patient feedback was considered alongside operational findings. The form is especially useful when multiple people contribute to the review and you need a consistent way to document what was examined, what was found, and what happens next.

Do not use this template as a general intake form or as a live eligibility application. It is not meant to collect every possible patient detail, and it should not be expanded into a broad data-capture tool. Keep the review focused on the minimum necessary information needed to evaluate the program, document any corrective actions, and record approval. If your organization needs site-specific or policy-specific branching, use conditional logic to show only the fields that apply.

Standards & compliance context

  • Keep data collection aligned with GDPR Article 5 data minimization by collecting only the patient and program details needed to evaluate the discount program.
  • If patient input includes PII, include a clear consent or disclosure field that explains how the information will be used and who can access it.
  • Use accessibility-friendly field labels, validation, and keyboard-safe controls so the form supports WCAG 2.1 AA expectations for public-facing or patient-facing workflows.
  • If the form is used in an HR or intake context for accommodation-related feedback, include a respectful prompt for reasonable accommodations and avoid unnecessary sensitive fields.
  • For health-related review data, follow the minimum-necessary principle by limiting access to only the reviewer, approver, and staff who need the findings.

General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.

What's inside this template

Review Details

This section anchors the review in time, names the reviewer, and defines exactly what program cycle is being evaluated.

  • Review Period Start Date (required)
  • Review Period End Date (required)
  • Date of Evaluation (required)
  • Reviewer Name (required)
  • Reviewer Title (required)
  • Review Scope (required)

Program Overview

This section identifies the policy and discount scale in effect so the evaluation can be tied to the correct program version.

  • Program Name (required)
  • Policy Version or Effective Date (required)
  • Sliding Fee Discount Scale Used (required)
  • Brief Program Summary (required)

    Describe how eligibility is determined, how discounts are applied, and any major changes since the last review.

Pay Class Data Review

This section checks whether the underlying classification data supports the discount decisions and highlights accuracy issues.

  • Data Source (required)
  • Total Patients Reviewed (required)
  • Pay Class Distribution (required)
  • Eligibility Determination Accuracy (required)
  • Key Findings From Pay Class Data (required)

Patient Input and Access Review

This section captures patient feedback and affordability barriers so the review reflects real access concerns, not just internal data.

  • Was patient input collected? (required)
  • Patient Input Method
  • Summary of Patient Feedback

    Summarize themes without including unnecessary PII. Use anonymous submission where appropriate.

  • Affordability Barriers Identified

Compliance Findings and Corrective Actions

This section turns the review into action by documenting gaps, assigning ownership, and setting completion dates.

  • Does the program currently meet internal policy and HRSA-related expectations? (required)
  • Identified Gaps
  • Corrective Actions (required)
  • Action Owner (required)

    Name or role responsible for follow-up; do not include unnecessary PII.

  • Target Completion Date (required)

Attestation and Approval

This section records the final sign-off and creates the audit trail showing the review was completed and approved.

  • Attestation (required)
  • Reviewer Signature (required)
  • Approval Status (required)
  • Approver Comments

How to use this template

  1. Enter the review period, review date, reviewer identity, and the exact scope so the form clearly shows which program cycle is being evaluated.
  2. Record the program name, policy version, and discount scale used so the review is tied to the correct policy and operating rules.
  3. Summarize the pay class data source, patient count, distribution, and eligibility accuracy, then note the specific findings that support your conclusion.
  4. Document how patient input was collected, what barriers were reported, and whether any accessibility or affordability issues need follow-up.
  5. List each compliance gap, assign an action owner, set a target completion date, and capture approval only after the review and corrective plan are complete.

Best practices

  • Use the exact policy version in effect during the review period so the findings can be traced to the correct discount scale.
  • Keep the review scope narrow and specific, such as one clinic, one program line, or one calendar cycle, instead of mixing unrelated reviews.
  • Mark required and optional fields clearly so reviewers do not over-collect data that is not needed for the evaluation.
  • Use numeric inputs for counts and date pickers for review dates and target completion dates to reduce entry errors.
  • Document patient input in a way that supports accessibility and privacy, and add anonymous submission if your feedback process needs it.
  • Assign every corrective action to a named owner with a real due date so the form produces follow-through instead of a static record.
  • Capture approval only after findings and actions are complete, not before, so the audit trail reflects the actual review sequence.

What this template typically catches

Issues teams running this template most often surface in practice:

The review period is incomplete or does not match the policy cycle being evaluated.
The discount scale used is not identified, making it hard to compare findings against the correct version.
Pay class data is summarized without showing the source, patient count, or eligibility accuracy checks.
Patient input is noted vaguely without documenting the collection method or the main affordability barriers.
Corrective actions are listed without an owner, target completion date, or clear follow-up path.
The form is approved before findings are fully documented, weakening the audit trail.
Too much patient detail is collected when a brief summary would meet the review need.

Common use cases

Community Health Center Compliance Review
A compliance manager uses the form to document the triennial review of a sliding fee discount program across one or more clinic sites. The structured sections make it easier to compare pay class data, patient feedback, and corrective actions in a single record.
Clinic Administrator Policy Update Check
After a discount scale update, a clinic administrator runs this evaluation to confirm the policy version in use, note any eligibility issues, and record whether the new scale is working as intended. The form helps separate the review from day-to-day patient intake.
Nonprofit Healthcare Board Packet
A nonprofit operations lead prepares the form for leadership review so the board can see the findings, gaps, and approvals in a consistent format. This is useful when leadership needs a concise audit trail rather than a narrative memo.
Multi-Site Affordability Barrier Review
A regional operations team compares patient input across several locations to identify common affordability barriers and site-specific issues. The form’s review scope and findings fields make it easier to route corrective actions to the right owner.

Frequently asked questions

What is this form used for?

This form documents a formal triennial review of a sliding fee discount program. It captures the review period, program details, pay class data, patient input, compliance findings, and any corrective actions. Use it when you need a repeatable record of how the discount scale is working and whether it still meets policy expectations.

How often should this evaluation be completed?

This template is designed for a review that happens at least every three years. Many organizations also use it sooner if the discount scale changes, patient volume shifts, or audit findings suggest the program needs a closer look. The review period fields make it easy to show exactly what time span was evaluated.

Who should complete the review?

A compliance lead, finance manager, clinic administrator, or designated reviewer with access to program records should complete it. The form includes reviewer name, title, and approval fields so the organization can show who performed the evaluation and who signed off on the result. If your process requires cross-functional review, you can add additional approvers.

What data should be included in the pay class review?

Include the data source, total patients reviewed, pay class distribution, and any notes on eligibility accuracy. The goal is to verify that the discount scale is being applied consistently and that the underlying classification data supports the program’s decisions. Keep the review focused on the minimum necessary data needed to assess the program.

Can patient feedback be collected anonymously?

Yes, if your process allows it, anonymous submission can be used for patient input to reduce reporting barriers. The template includes fields for patient input method and feedback summary, which lets you document whether comments came from surveys, interviews, suggestion forms, or another channel. If you collect PII, add a clear disclosure about how it will be used.

What are the most common mistakes when using this template?

Common mistakes include leaving the review scope too vague, skipping the patient input section, and documenting corrective actions without assigning an owner or due date. Another frequent issue is treating the form like a narrative memo instead of a structured review with findings and approvals. Clear validation and required-versus-optional fields help prevent those gaps.

How can this form be customized for our organization?

You can tailor the program overview fields to match your policy version, discount scale, and internal terminology. Many organizations also add conditional logic for different clinic sites, reviewer roles, or corrective action types. If your workflow includes an audit trail or e-signature step, connect those fields to your approval process.

How does this compare with doing the review in a spreadsheet or email thread?

A spreadsheet or email thread can capture pieces of the review, but it often leaves gaps in accountability, approvals, and follow-up tracking. This template keeps the review in one structured form with consistent fields for findings, actions, and sign-off. That makes it easier to reuse, audit, and compare across review cycles.

Related templates

Forms

Release of Information Consent (Social Services)

This Release of Information Consent (Social Services) template captures exactly what can be share...
Forms

PRN Psychotropic Medication Effectiveness Note

Track whether a PRN psychotropic medication worked, what behavior it was given for, and what foll...
Forms

Medical Records Release Form

A Medical Records Release Form for authorizing a provider to send specific records to a named rec...
Forms

School-Based Outreach Visit Log

A structured log for youth-serving outreach staff to document every school visit — classrooms rea...
Forms

Restraint Consent and Monitoring Form

A restraint consent and monitoring form for documenting why restraint was used, who authorized it...
Inspections

340B Contract Pharmacy Quarterly Self-Audit Worksheet

Use this quarterly worksheet to review 340B contract pharmacy claims for diversion, duplicate dis...
Sop

Front Desk Patient Check-In SOP for Multi-Site Physician Group

Front Desk Patient Check-In SOP for Multi-Site Physician Group standardizes greeting, identity ch...
Hr Policy

Anti-Harassment & Anti-Discrimination Policy

Anti-Harassment & Anti-Discrimination Policy template for defining prohibited conduct, reporting ...

Go deeper on the topic

Related concepts
  • Lockout/Tagout
    Lockout/tagout (LOTO) is the procedure for controlling hazardous energy — electrical, hydraulic, pneumatic, mechanical, thermal, chemical — before...
  • Job Hazard Analysis
    Job hazard analysis (JHA) — also called job safety analysis (JSA) — is the structured exercise of breaking a work task into sequential steps, identifying the...
  • Near-Miss Reporting
    A near-miss is an event that could have caused injury or damage but didn't — a slip that didn't fall, a load that shifted but didn't drop, a machine that...
  • AI Governance
    AI governance is the framework a company uses to decide what AI tools are allowed to do, who's accountable for their outputs, what data they're allowed to...
Related guides

Ready to use this template?

Get started with MangoApps and use Sliding Fee Discount Program Triennial Evaluation Form with your team — pricing built for small business.

Get Started