Waiver Client Registration - Scene Clean, Inc.

Step 1 New Waiver Client Registration

9/30/2019 we no longer accept waiver participants through UCARE. We are sorry for the inconvience this may cause.

To start the waiver registration process you must complete the form below. This is the first step of a three step process case managers will need to follow.

After submission of the form, do not hit the back button, your form will not be submitted unless you are taken to the confirmation page. If you are not automatically taken to the confirmation page your submission did not go through and you will need to re-submit.

ATTENTION CASE MANAGERS Upon registration you will still need to complete the following steps;

Once the referral has been accepted by Scene Clean you will need to return to the website to complete step 2.
After completing step 2 you will schedule the assessment with the client. After the assessment is completed the assessment will be emailed to you for approval of the units requested.
After approval of the units requested to perform services you will return to complete step 3.

Scene Clean’s NPI # is 1265842785

Step 1 of 4 - Worksite Info

Today's Date*
Today's Date
Date Format: MM slash DD slash YYYY
County of the Client*
County of the Client.
Client PMI number*
Clients PMI number:
Service(s) Requested*
Services(s) Requested. Select all that apply.
- BioHazard Remediation
- Hoarding Cleanup
- Gross Filth Cleanup
- Pest Control
- Bed Bug Preparation
Client Diagnosis Code(s)*
Diagnosis Code(s) numbers only, separate with coma:
Client Name*
Clients Name:
First Middle Last
Client Birthdate*
Clients DOB:
Date Format: MM slash DD slash YYYY
Client Phone
Client Phone:
Clients Sex*
Clients Sex:
- Male
- Female

Waiver Type*
Waiver Type
Payee*
Clients Payee:
Out of Pocket
Does the client have any out of pocket financial responsibility? Co-Pay, spend down, please explain. Amount in $ is preferred.
Other Payee Explained*
Other Payee Explained:
Client Address*
Clients Address:

Street Address Address Line 2 City State ZIP Code
File Notes*
Tell us, in detail, what you are looking to have done and any notes.

Case Manager*
Case Manager Name:
First Last
Case Manager Phone*
Case Manager Phone:
Case Manager Email*
Case Manager Email:
Company Name*
Case Manager Company:

- Case Managers;
Please read all of the information on this page carefully to make sure you have a full understanding of what needs to be done to complete the registration, begin the next step of an assessment and ultimately the cleanup service. You have multiple steps that must be completed during the registration and approval process. Please note the entire process is done via email, please check your email often.
1. Submit registration and what to expect next after submission of this registration;
Within 72 business hrs. we will reach out to you to accept the registration and assign it a job number. While waiting for our acceptance you will need to get approval of the assessment units described in item 3 below and follow those instructions. You will need the job number in order to complete section 3 and input the SA number for the client. Please be sure to use that job number in all email communication by placing it in the subject line.
1. Services requested;
We do not perform “deep cleaning” as a stand-alone service. We are a biohazard removal company and not setup to perform standard cleaning tasks such as dusting, window washing etc. A deep cleaning can be requested in connection with services we do offer such as; hoarding cleanup, gross filth cleanup or biohazard cleanup but is subject to availability and focused on he areas we treated for hoarding. Our goal is to perform services that allow ongoing regular services such as “Homemaking” to take over afterwards. Our services are not typically long term but rather one time.
1. Assessment fee;
After this client registration your next step in the process is to obtain approval for the assessment units and return to our website to fill out step 2 (blue button). Once you complete the Step 2 submission you may schedule the assessment online or by email or phone. No Assessments will be scheduled without this information.

The following tiers indicate the number of units needed for the assessment;

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
1. Scheduling of the assessment;
All scheduling is performed through you as the case manager. We do not arrange appointments through the clients as this adds a layer of support and accountability. We have found this the best way to avoid missed assessments.

We reserve the right to bill for any and all missed assessments. If your client should no show (or not answer the door) we will require an additional SA assessment for a second trip.
1. UCare clients;
If your client us a UCare participant we understand that you do not receive the SA information and it will come from UCare. We do require notification from UCare before we will begin the assessment process and ultimately the service scheduling. We are sorry but there are no exceptions to this rule. UCare will fax us an authorization and we will use this fax versus waiting for the paper copy in the mail which does help to speed up to process.
1. Receiving the written assessment after the assessment;
All assessments are sent to the email address you provided during this registration. Toward the back of the assessment you will find the estimated number of units we are requesting. This is the number of units you will need to submit for approval. Please be sure to also ask for a range of dates for the approval so we can be sure to perform services and not run into billing issues. Many times we perform our services when the client is in the hospital or nursing home in order for them to be allowed back into the home. This creates an issue for allowable billing dates, if this is the case please keep us posted on date(s) we can use for billing purposes.

Please note that with our services you are purchasing a block of time based off of our assessment and the estimate. We will work within that block of time to perform services for the client. Due to the conditions of some clients homes we may not be able to complete the project in its entirety and we will work until the block of time has expired. Should a time limit be reached you will be contacted with an additional request for more units to complete what is left.

No projects are a “bid.” All projects are billed for time and materials, as there are many variables outside of our control that can play a role in our efficiency onsite. It is always our goal to be as close to the estimate’s time and costs as possible.
1. Approval of services;
Once you have received approval of the units for the service you will once again return to the Waiver page on the website to input the SA number on the step 3 button (Green Button). Once this information is submitted on our website, it will trigger our system to reach out and schedule services to be performed.
1. Important things to note with Waiver clients;
We are not a regulatory agency. We cannot force clients to comply with removal of personal contents. Please understand if the client is facing eviction or housing issues due to their living conditions, we will make every attempt to rectify the situation and achieve a successful cleanup while focusing on safety issues first and foremost. However, we cannot force anyone against their will to dispose of items in order to pass any such inspection.
Acceptance*
I understand after submission of this referral Scene Clean will typically reach out via email within 72 business hours with an acceptance or denial of the referral. If you do not see any email from Scene Clean it is often because it may be in a junk folder, please check there first before calling us. All assessment and service scheduling are done through the case managers. Scene Clean does not directly set up appointments with the client to add a layer of accountability.
- I have read and understand the above.
Case Manager Signature*
Case Worker Signature
Name
This field is for validation purposes and should be left unchanged.