Assessment-SA Input - Scene Clean, Inc.

Step 2 Assessment SA Input

The assessment is an important part of the waiver process which involves an onsite visit at which time we are evaluating if the services we offer fit the needs of the client. During the assessment we are also gathering the information we will need to complete an estimate of costs and a plan of action to complete the actual services. The assessment is just that, an assessment and no cleaning services are performed during the assessment. Case managers do not need to attend the assessment.

In order to fill out this step, step 2, you must have already completed the registration process in step 1 and have been assigned a job ID number by Scene Clean. The assessment will need units approved as described below. Units are billed under chore services S5120.

Assessment Tiers and Units needed;

Tier 1 is 39 units; Anoka, Hennepin and Ramsey Counties

Tier 2 is 52 units; Carver, Dakota, Scott, Sherburne, Washington, Wright Counties

Tier 3 is 66 units; Benton, Chisago, Goodhue, Isanti, Kanabec, Meeker, Mille Lacs, Pine, Rice, Stearns Counties

With all service agreements please be sure to have a range of dates approved to accommodate any unforeseen scheduling issues.

Assessments are scheduled Mondays from 9am-4pm and Fridays from 9am-2pm in 1 hour arrival windows.

Prior to filling out this form it may be helpful to have dates and times the client is available as the assessment can now be scheduled online after submission of step 2.

DO NOT HIT THE BACK BUTTON UPON SUBMISSION, You will be taken to a confirmation page. If you do not go to a confirmation page your submission did not go through and you will need to re-submit.

Today's Date*
Today's Date
Date Format: MM slash DD slash YYYY
Job Number*
Job ID (Provided upon client acceptance by Scene Clean, 5 digits)
Client Last Name*
Client Last Name:
Last
Case Manager Email*
Case Manager's Email:
Units Approved*
Please verify the units approved for the assessment.
SA Valid Start
Service Auth. Valid From:
Date Format: MM slash DD slash YYYY
SA Valid Until*
Service Auth. Valid Until:
Date Format: MM slash DD slash YYYY
SA Number*
Enter Service Authorization Number:
Clients PMI number:*
Enter the Clients PMI number:
SA File*
Please provide a copy of the SA approval specifically for Scene Clean (pdf or screenshot). Due to numerous billing issues we will no longer provide the service until we receive verification.
Drop files here or
Assessment Scheduling*
All assessments are scheduled through the case manager. Scene Clean does not schedule assessments with the client directly to create a layer of accountability. Please have 2-3 dates and times available when submitting this form to expedite the scheduling of the assessment. Assessments are done on Mondays from 9-4 and Fridays from 9-2 with a 1 hour arrival windows. Online scheduling is available after submission of this form.
- I understand I will be scheduling the assessment with the client.
Case Manager Signature*
I verify the above is correct.
Name
This field is for validation purposes and should be left unchanged.