Onsite Evaluation-SA Input - Scene Clean, Inc.

Step 2 Onsite Evaluation SA Input

Please DO NOT submit this form more than once.

If you need to change the onsite evaluation time after using this form to schedule you can do so by checking the appointment confirmation email received from Calendly after the initial scheduling of the appointment.

The onsite evaluation 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 onsite evaluation, we are also gathering the information we will need to complete an estimate of costs, contacting third parties, assessing necessary logistics, and create a plan of action to complete the actual services. The onsite evaluation is just that, an evaluation and no cleaning services are performed during the onsite evaluation. Case managers do not need to attend the evaluation. The written evaluation will be placed into the client portal upon completion.

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 onsite evaluation is billed under chore services S5121.

Onsite Evaluation Costs;

Tier 1 is $0.00; Anoka, Hennepin and Ramsey Counties

Tier 2 is $175.00; Carver, Dakota, Scott, Sherburne, Washington, Wright Counties

Tier 3 is $295.00; Benton, Chisago, Goodhue, Isanti, Kanabec, Meeker, Mille Lacs, Pine, Rice, Stearns Counties

Case by Case costs: You will need to obtain the case-by-case cost from Scene Clean prior to completion of this form.

All missed/no-show evaluations or evaluations canceled within 24 hrs. will be billed in full. Missed Tier 1 appointments will require a fee to reschedule.

ATTENTION-MUST READ

Prior to filling out this form have a few dates and times the client is available to schedule the onsite evaluation which is to be done online. Upon completion of this form, you will be taken to the online scheduler. Please DO NOT submit this form again if you are unable to schedule online. Instead, email your POC and ask for a one-time scheduling link.

Onsite Evaluations are scheduled Mondays from 8am-330pm and Fridays from 8am until 230pm in 1 hour arrival windows.

Job Number*
Job ID (5 Digit JOB ID is provided to you upon registration by Scene Clean, DO NOT submit this form until you have received this ID number)
Today's Date*
Today's Date
MM slash DD slash YYYY
Client Last Name*
Client Last Name:
Last
Clients PMI number:*
Enter the Clients PMI number:
Costs Approved*
Please verify the cost that has been approved for the onsite evaluation.
Case By Case Cost*
Enter cost for Case by Case provided to you by Scene Clean. Either email your point of contact or call 612-643-0911 to obtain the unit amount.
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
Case Manager Email*
Case Manager's Email:
Prior to submission of this form, all case managers are required to have submitted the appropriate unit requirement determined by the tier level of the client.*
Prior to submission of this form, all case managers are required to have submitted the appropriate unit requirement determined by the tier level of the client.
I have submitted and have the cost approved for the onsite evaluation.
All onsite evaluations are scheduled through the case manager. Scene Clean does not schedule evaluations with the client directly to create a layer of accountability (sub-contracted services are scheduled by the contractor). Please have 2-3 dates and times available when submitting this form to expedite the scheduling of the Onsite evaluation. Onsite Evaluations are done on Mondays from 8-3:30 and Fridays from 8-2:30 with a 1 hour arrival windows. Online scheduling is available after submission of this form, please have dates ready to schedule online.*
All onsite evaluations are scheduled through the case manager. Scene Clean does not schedule evaluations with the client directly to create a layer of accountability (sub-contracted services are scheduled by the contractor). Please have 2-3 dates and times available when submitting this form to expedite the scheduling of the Onsite evaluation.

Onsite Evaluations are done on Mondays from 8-3:30 and Fridays from 8-2:30 with a 1 hour arrival windows. Online scheduling is available after submission of this form, please have dates ready to schedule online.
I understand I will be scheduling the onsite evaluation with the client and notified the client of the 1 hour window.
Missed appointments, not answering of the door or cancellations inside of 24 hrs. will be billed in full. In order to re-schedule the onsite evaluation additional units will be required.*
Missed appointments, not answering of the door or cancellations inside of 24 hrs. will be billed in full. In order to re-schedule the onsite evaluation additional units will be required.
I understand the cancellation policy.
Upon completion, typically between 24-72 hrs., the completed onsite evaluation will be placed into the portal. An email will be sent to the email provided upon registration notifying the written evaluation is in the portal.*
Upon completion, typically between 24-72 hrs., the completed onsite evaluation will be placed into the portal. An email will be sent to the email provided upon registration notifying the written evaluation is in the portal.
I understand the written onsite evaluation will be placed into the portal.
Email
This field is for validation purposes and should be left unchanged.

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.