Patient Experience Policy Forum (PXPF) - Support Commitment Form

The Patient Experience Policy Forum (PXPF) relies on sponsorship funding to support operations, provide access to all interested individuals and enable the engagement and participation of patients and families. We invite healthcare organizations and vendors to sponsor and support the Forum and appreciate your consideration of support for our efforts. You can find information on the PXPF including our charter and member standards on our site via this link: www.pxpolicyforum.org.

To be eligible supporters must agree and adhere to the PXPF support policy (in development). Supporters do not dictate direction, focus or goals of PXPF. Support is offered in the interest of the purpose of PXPF itself.

To start the contribution process, please provide the information requested below and we will generate and send an invoice to your organization for the amount you specify below. Thank you for your consideration.

Question Title

* Primary Contact Information

First Name

Last Name

Title

Email Address

Phone Number

Question Title

* Organizational Information / Billing Address

Organization Name

Address

Address 2

City

State / Province

ZIP/Postal Code

Country

Question Title

* Level of Support: Please identify your level of support as an organizational partner.

Organizational partnerships are exclusively offered for healthcare delivery/provider organizations that wish to support the efforts of PXPF. Benefits for Organizational Partners include:
▪      Identified on PXPF website as Organizational Partner at level of investment
▪      Identified in public presentations from PXPF
▪      One complementary participant registration provided for each in-person meeting

GOLD Organizational Partner - $5,000

SILVER Organizational Partner - $2,500

I am an individual contributor interested in supporting PXPF. Please provide me with additional information.

Organizational Partner - Other amount as specified (for organizations wishing to contribute MORE THAN the listed options above)

Question Title

* Use of Contribution: With your contribution we offer the option to designate how your funds are allocated for use. Please select how you wish your funds to be used below.

Please designate our funds for ALL needs

Please designate our funds specifically for the Operational Support of PXPF

Please designate our funds specifically to support Patient and Family Participation in PXPF

Thank you in advance for your commitment to and support of the Patient Experience Policy Forum.