Clemens Health | Provider-transition discussion 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.

Reason and priorities
Why is a change being considered, and what does the person want to improve?
Your notes: ________________________________________

Current arrangement
What support is in place and which requirements need checking before a change?
Your notes: ________________________________________

Proposed arrangement
What has the new provider confirmed and what remains tentative?
Your notes: ________________________________________

Handoff responsibilities
Who coordinates dates, permissions, information and introductions?
Your notes: ________________________________________

Unresolved gap
What support or decision could remain uncovered, and who will address it?
Your notes: ________________________________________

Illustrative example
A person wants a different visit time. A new provider can discuss the request but has not confirmed staffing. The case manager keeps the proposed start separate from the existing arrangement and asks both teams to clarify transition requirements.

Next step
Use the worksheet at a transition conversation. Obtain the relevant confirmations before treating a provider change or date as final.

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.