Schedule Service SA - Scene Clean, Inc.

Step 3 Schedule Service SA Input

Please input the client’s Service agreement information below.

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

In order to fill out step 3 you must have already completed Step 1 and 2. As part of Step 2, the onsite evaluation, you will have received a written evaluation with the cost requested for the actual service which you will enter on this form.

Services for waivers are scheduled Tuesdays, Wednesdays and Thursdays.

Job Number*
Job ID (provided upon client acceptance by Scene Clean, 5 digits)
Todays Date*
Today's Date
MM slash DD slash YYYY
Client Last Name*
Client Last Name:
Last
Clients PMI Number:*
Enter clients 8 digit PMI number.
Costs Approved*
Verify the cost approved for the actual service. DO NOT include the cost already approved for the onsite evaluation, they are separate charges. This is in addition to the onsite evaluation cost already approved.
SA Number
11 digit SA Number incl. leading zeros (if known please provide):
SA Valid Start
Service Auth. Valid From:
MM slash DD slash YYYY
SA Valid Until*
Service Auth. Valid Until:
MM slash DD slash YYYY
Proposed Service Date 1
2 Proposed service dates Tue-Thur only. We will confirm a date with the case manager via email typically within 72 hrs. Appointments are subject to availability. For requested dates within a week please email your POC. We are typically scheduled 1 to 2 weeks out.
MM slash DD slash YYYY
Proposed Service Date 2
Proposed Service date Number 2. We will confirm a date with the case manager via email typically within 72 hrs. Appointments are subject to availability. For requested dates within a week please email your POC. We are typically scheduled 1 to 2 weeks out.
MM slash DD slash YYYY
Case Manager Email*
Case Manager's Email:
I have read the scope of work to be performed listed within the written evaluation sent to me. I understand Scene Clean does not provide basic cleaning services such as dusting, vacuuming, washing dishes, etc. (Typical services performed by Homemaking). Work within the scope will be performed as allowed by the client or the condition of the property itself, severely damaged surfaces may not be able to be cleaned very well. If you have not be sure to review the scope of work on the onsite evaluation.*
I have read the scope of work to be performed listed within the written evaluation sent to me. I understand Scene Clean does not provide basic cleaning services such as dusting, vacuuming, washing dishes, etc. (Typical services performed by Homemaking).

Work within the scope will be performed as allowed by the client or the condition of the property itself, severely damaged surfaces may not be able to be cleaned very well. If you have not be sure to review the scope of work on the onsite evaluation.
I have read and understand the scope of work to be performed.
Scene Clean may delay scheduling of services until verification of the service authorization. Service cancellations inside of 48 hrs. or missed appointments will be charged in full.*
Scene Clean may delay scheduling of services until verification of the service authorization. Service cancellations inside of 48 hrs. or missed appointments will be charged in full.
I understand verification is needed and the cancellation policy.
I have verified that the service cost I have submitted for approval DID NOT include the cost for the onsite evaluation. The costs for the actual service was submitted as found on the written evaluation.*
I have verified that the service cost I have submitted for approval DID NOT include the cost for the onsite evaluation. The costs for the actual service was submitted as found on the written evaluation.
I have verified the cost did NOT include the written evaluation.
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DO NOT HIT THE BACK BUTTON. You will be taken to a confirmation page upon successful submission of this form. If you do not go to the confrimation page your submission did not go through and you will need to re-submit.