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Table 1 PAF Checklist located in electronic health record (EHR)

From: Development and implementation of a patient assistance fund: a descriptive study

Patient Assistance Fund (PAF) Checklist
Tab 1 – General Information
Student Name  
Patient Name  
Proposed Treatment Plan/Treatment Codes  
Treatment Plan approved by faculty Yes No
Treatment Plan approved by patient Yes No
General Consent, Screening, and Comprehensive Exam Consent, PAF Consent all signed Yes No
Income Eligibility Requirements Passed Yes No
Tab 2 – Patient Circumstances
Brief synopsis of patient circumstances/why patient should be considered for funding  
Tab 3– Approval or Denial
Approved Yes No
Denial Reasoning  
Request for more information