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FH-CL-010 • VERSION 1.0
Service Change, Suspension, Resumption & Termination
Documents any change in services and the reason, notice and outcome.
Digital workflow:
Complete required fields, review carefully, then submit. A submitted record is timestamped and preserved for office review.
1. Record identification
Client name *
Date *
Completed by *
2. Requested action
Action *
Choose…
Service change
Temporary suspension
Resume services
Terminate services
Requested / effective date
Requested by
Reason
Changes to schedule, services or limits
Safety or scope concern
Notice and contacts completed
Final disposition / follow-up
3. Certification / acknowledgment
Electronic signature / typed name *
Signature date *
Notes
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