Ongoing Service Adjustments "*" indicates required fields Client InformationClient's First Name*Client's Last Name*Client's PMI*Client's Date of Birth*Case Manager InformationCase Manager Name*Case Manager Phone*Case Manager Email* Adjustment InformationServices to Adjust* Bus Passes Lyft Pass Specialty Transportation Lawn Care Snow Removal Service Continuation During Adjustment* Start new services while awaiting the adjusted service agreement (pending unit availability). Continue existing services until the adjusted service agreement is received. Stop existing services immediately and start the new services once the adjusted service agreement is received. Service Changes We cannot guarantee that services can be switched prior to receiving the adjusted Service Agreement. Service changes are dependent on unit availability within the current Service Agreement. Decrease in services* I understand.*Service Adjustment Type* Increase in services Decrease in services Change in schedule Change in vendor Service termination Other Decrease in Services Requests to decrease services can only be applied to future months of service. Due to invoice variability by service date, decreases cannot be processed for the current month. Decrease in services* I understand.*Requested Date of Adjustment* Detailed Explanation of Adjustment:*Include: Current vs. requested units or dollar amounts, vendor changes (if applicable) and schedule or frequency changesReason for Adjustment* Change in assessed need Health / safety concern Vendor availability Individual preference Budget / funding change Other Explanation of Request*Provide a clear explanation of the reason for this request, including any recent changes, risks, or supporting context.Acknowledgement* I acknowledge that service adjustments are subject to funding authorization, required documentation, provider availability, and standard processing timelines. Changes are not guaranteed, are not immediate, and cannot be applied retroactively. Adjustments may result in temporary gaps in service. I understand that this form may only be used to adjust existing, ongoing services. Requests for new services will not be processed and must be submitted through a new referral form.
