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Run: Sliding Fee Discount Program Triennial Evaluation

A triennial evaluation form for reviewing your sliding fee discount program, documenting pay class data, patient input, access barriers, and approval actions...

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Evaluation Overview

Evaluation Period Start Date (required)

Start date of the three-year review period.

Evaluation Period End Date (required)

End date of the three-year review period.

Evaluator Name (required)

Name of the person completing the evaluation.

Evaluator Role or Department (required)

Role, team, or department responsible for the review.

Review Completion Date (required)

Date the evaluation was completed.

Program Structure Review

Pay Class Structure Reviewed? (required)

Confirm whether current pay class definitions were reviewed.

Number of Pay Classes (required)

Enter the current number of pay classes used in the program.

Policy Changes Since Last Review

Select any changes made since the prior triennial evaluation.

Describe Other Policy Changes

Provide details only if 'Other' was selected.

Accessibility Assessment (required)

Rate how easy it is for patients to understand and access the program.

Pay Class Data Analysis

Total Applications Reviewed (required)

Number of sliding fee applications included in the review.

Approved Applications (required)

Number of applications approved during the review period.

Denied Applications (required)

Number of applications denied during the review period.

Most Common Pay Class (required)

Select the pay class assigned to the largest share of eligible patients.

Pay Class Trend Summary (required)

Summarize notable trends, shifts in distribution, or concerns identified in the pay class data.

Discount Structure Effectiveness (required)

Rate how well the current discount structure matches patient need and program goals.

Patient Input and Access Barriers

Was Patient Input Collected? (required)

Indicate whether patient feedback was gathered for this evaluation.

Patient Input Method

Select the methods used to gather patient input.

Patient Feedback Summary

Summarize what patients said about eligibility, application steps, communication, and fairness.

Identified Access Barriers

Select any barriers identified through patient input.

Barrier Details

Provide specific examples or context for the barriers identified.

Findings, Actions, and Approval

Overall Findings (required)

Summarize the evaluation findings and whether the program remains appropriate.

Recommended Actions (required)

List action items needed to improve the program.

Implementation Priority (required)

Select the overall priority for follow-up actions.

Approval Status (required)

Current approval status for the evaluation record.

Approver Comments

Add comments if the evaluation needs revision or is pending approval.

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