Clemens Health | Authorization and staffing status sheet
Updated 2026-10-05 | (651) 354-1196

Download this editable worksheet, add your notes, and bring it to the relevant planning conversation. Leave unknown details blank and identify who can confirm them.

Service request
What exact service, location and schedule are under discussion?
Your notes: ________________________________________

Authorization status
What is confirmed, what is pending, and who supplied that information?
Your notes: ________________________________________

Staffing status
What arrangement has the provider checked or confirmed, and when?
Your notes: ________________________________________

Remaining start requirements
What documents, introductions or other agreed steps remain?
Your notes: ________________________________________

Start communication
Who will confirm the date to the person and relevant team members?
Your notes: ________________________________________

Illustrative example
An authorized request includes weekday support, but the provider is still checking Friday coverage. The coordinator explains that authorization is in place while the full staffed pattern remains unconfirmed.

Next step
Use the two statuses in referral updates and start-date discussions. Recheck both when the requested arrangement changes.

This is an optional discussion worksheet, not an official assessment, authorization, service plan, or emergency plan. Keep completed copies private and share through an agreed channel.