Step 3 Schedule Service SA Input

 

Please input the clients 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 assessment, you will have received an estimate with the units requested for the actual service which you will enter on this form. The units requested are on page 6 of the estimate and are in addition to the assessment units from step 2. 

 

 

Services for waivers are scheduled Tuesdays, Wednesdays and Thursdays. 

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
    Date Format: MM slash DD slash YYYY
  • Job ID (provided upon client acceptance by Scene Clean, 5 digits)
  • Client Last Name:
  • Case Manager's Email:
  • Verify the units approved for the actual service. DO NOT subtract the units already approved for the Assessment, they are separate charges. This is in addition to the assessment units already approved.
  • Service Auth. Valid From:
    Date Format: MM slash DD slash YYYY
  • Service Auth. Valid Until:
    Date Format: MM slash DD slash YYYY
  • Enter Service Authorization Number:
  • Enter Clients PMI Number:
  • 2 Requested 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.
    Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Please provide a copy of the SA approval specifically for Scene Clean (pdf or screenshot).
    Drop files here or
  • I verify the above is correct.
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