Clemens Health | IHS provider interview record
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.

Provider and contact
Who spoke with you, on what date, and how can you follow up?
Your notes: ________________________________________

Specific request
Which routine, address area and proposed days did you discuss?
Your notes: ________________________________________

Confirmed fit
What did the provider confirm, and what is still being checked?
Your notes: ________________________________________

Worker and communication
How are preferences, introductions, concerns and schedule changes handled?
Your notes: ________________________________________

Next decision
Who will respond next, about what, and when should you check back?
Your notes: ________________________________________

Illustrative example
Two providers say they offer IHS. One confirms a conversation about Tuesday afternoons; the other has not yet checked that time. The comparison record marks one schedule as under discussion and the other as unknown, rather than treating both as available.

Next step
Contact Clemens Health about the location, routine and schedule you want to discuss. Ask the team to confirm service fit and staffing before agreeing on a start date.

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.