Waiver Client Registration - Scene Clean, Inc.

Today's Date
Today's Date
MM slash DD slash YYYY
County of the Client*
County of the Client.
Client PMI number*
Clients PMI number (include leading zeros):
Client Diagnosis Code(s)*
Diagnosis Code(s) letter and number, separate with coma:
Service(s) Requested*
Services(s) Requested. Select all that apply.
- BioHazard Remediation
- Hoarding Cleanup
- Gross Filth Cleanup
- Pest Control (Sub-Contracted)
Tenant?*
Is the client a tenant of this property? Tenants are not eligible for pest control services on the waiver program. Landlords must provide pest control services per the rules on MN DHS.
- No
- Yes
Client Name*
Clients Name:
First Middle Last
Client Birthdate*
Clients DOB:
MM slash DD slash YYYY
Client Phone
Client Phone:

Waiver Type*
Waiver Type
Payee*
Clients Payee:
Out of Pocket
Does the client have any out of pocket financial responsibility? Co-Pay, spend down, etc., please explain. Amount in $ is preferred. Payment due at the time of service.
BCBS/Bridgeview Client ID*
Client ID number for BCBS/Bridgeview?
Other Payee Explained*
Other Payee Explained i.e. trustee, self etc.
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 onsite evaluation 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 and online, 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 onsite evaluation 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 “detailed cleaning”. We are a biohazard removal company and not setup to perform standard cleaning tasks such as dusting, window washing, vacuuming, washing dishes etc. We do not clean carpets. We typically have a focused goal of making the kitchen surfaces and bathroom surfaces sanitary. Our goal is to perform services that allow ongoing regular services such as “Homemaking” to take over afterward. Our services are not typically long-term but rather one-time.
1. Scheduling of the onsite evaluation;
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 onsite evaluations.

We reserve the right to bill for any and all missed onsite evaluations. If your client should no show (or not answer the door) we will require an additional Service Authorization for a second trip.
1. Medica/HealthPartners clients;
If your client is a MEDICA or HealthPartners participant we understand that you do not receive the SA information and it will come from Medica or HealthPartners. We do require notification from Medica/HP before we will begin the onsite evaluation process and ultimately the service scheduling. We are sorry but there are no exceptions to this rule. Medica or HealthPartners 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 onsite evaluation after the onsite evaluation;
All onsite evaluations are sent to the email address you provided during this registration. Toward the back of the evaluation you will find the estimated cost we are requesting. 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 on our onsite evaluation and the estimate. We will work within that block of time to perform services for the client. Due to the conditions of some client's 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. 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.
Personally visited?*
Have you personally visited the property and can attest to the services requested?
No Inspection Reason*
Please describe why you have not been able to perform and onsite visit. Please note, we no longer accept COVID as a valid reason. We expect case managers or someone from their agency to have personally seen and witnessed the services the client is in need of.
Photo(s)
If you have indicated a third party has sent pictures than provide those pictures to us for review.
Drop files here or

Accepted file types: jpg, png, gif, Max. file size: 512 MB, Max. files: 6.

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 onsite evaluations 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.
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Step 1 of 5 - Worksite Info