Clemens Health | Authorization and schedule reconciliation record
Updated 2026-10-05 | (651) 354-1196

Use the actual documents during the discussion. Leave uncertain entries unresolved until the issuing agency or responsible provider explains them.

Document identity
Record title, issuer, version and date.
Illustrative entry: Latest service agreement received; previous copy retained and labeled.
Your notes: ________________________________________

Service wording
What service or option appears, and who explained it?
Illustrative entry: Exact wording copied privately; explanation requested from case manager.
Your notes: ________________________________________

Effective period
Which dates apply to the arrangement being discussed?
Illustrative entry: Start and end dates to be checked against requested visits.
Your notes: ________________________________________

Amount and unit
How is the authorized amount expressed?
Illustrative entry: Unit definition still needs confirmation; no weekly estimate entered.
Your notes: ________________________________________

Provider readiness
What has the provider separately confirmed?
Illustrative entry: Intake accepted; worker assignment remains open.
Your notes: ________________________________________

Discrepancy
Which two records disagree, and who will resolve it?
Illustrative entry: Requested start and document date differ; issuer to clarify.
Your notes: ________________________________________

Resolution
What was confirmed and who received the update?
Illustrative entry: Record the corrected version and scheduling contact's acknowledgment.
Your notes: ________________________________________

Illustrative example
A coordinator forwards an older agreement alongside a new proposed schedule. The provider notices that the document's end date falls before the requested first visit. Instead of assuming services will be renewed, the coordinator checks with the issuer and obtains the current document. The worksheet records which version was replaced and when the provider acknowledged the update. Worker assignment is still listed as pending. Resolving the paperwork discrepancy therefore does not accidentally turn into a claim that a start date is confirmed.

Next step
Resolve the specific document questions with the issuing team, then ask the provider to confirm its schedule and first-visit arrangements.

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.