Hospital Charity Care / Financial Assistance Application Log PDF
Log submissions, confirmations, statuses, and follow-ups for hospital charity care applications.
Log your charity care submissions
Track when you submitted documents, who received them, statuses, and follow-up dates.
Status message placeholder
Empty values are allowed. Keep everything in one printable table.
| Date Submitted | Department / Office | Submission Method | Documents Included | Confirmation / Receipt # | Status | Follow-up Date | Notes | Actions |
|---|---|---|---|---|---|---|---|---|
No calculations applied. Export exactly what you enter.
🔒 MANDATORY CODEX SAFETY FOOTER (INCLUDE VERBATIM)
- Do not modify global layout, header, footer, ads, analytics, or shared components
- Do not import @/components/ui/select or any unverified shadcn components
- Use native HTML inputs only
- Row add/remove buttons must be plain <button>
- No date math, no parsing, no calculations
- PDF builders must return Promise<Uint8Array>
- Always create Blobs using bytesToPdfBlob(bytes) from lib/pdf/bytes.ts
- Never include null in React-PDF style arrays
- No refactors
- Tool may only break itself