• Sliding Fee Scale Audit Checklist Form

    Use this form to review whether sliding fee scale procedures are posted, documented, and applied consistently during the audit period.

  • Audit Overview

  • Audit Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Sliding Fee Scale Checklist

  • Sliding fee scale policy is posted and current*
  • Proof of income documentation is verified*
  • Household size is documented*
  • Fee determination follows the scale*
  • Discounts are applied consistently*
  • Required signatures or approvals are present on the file when applicable*
  • Exceptions are documented*
  • Follow-up action is needed*

  • Audit Findings and Follow-Up

  • Should be Empty:
Select theme: