PURPOSE

The purpose of this form is for Consumer Directed Services (CDS) Employers to request to use the CDS Employer’s cell phone number or to request additional phone numbers for the Electronic Visit Verification (EVV) system.

EVV is a telephone and computer-based system that documents the time your attendant starts and ends delivering services to you.

EVV will impact agency providers, Consumer Directed Services Agencies (CDSAs), and all CDS individuals who receive the following services:

• personal assistance services and in-home respite services in the Community Based Alternatives (CBA) program;
• residential habilitation and in-home respite services in the Community Living Assistance and Support Services (CLASS) program;
• in-home respite services and adjunct support services in the Medically Dependent Children Program (MDCP);
• Primary Home Care program (PHC) as described in 40 Texas Administrative Code (TAC) §47.3(20);
• Community Attendant Services (CAS) as described in §47.3(3), and
• Family Care (FC) services as described in §47.3(11).

PROCEDURE

When to Prepare

If the CDS employer requests to use a cell phone or requests to use a second landline for the EVV system, the CDSA sends this form to the CDS individual for completion and submittal to the CDSA.

Number of Copies

One original for the CDSA and one copy for the CDS Employer.

Transmittal

The CDSA gives a copy of the Form 1723 to the individual.

Form Retention

The CDSA retains a copy of Form 1723 in the case folder.

DETAILED INSTRUCTIONS

1. Individual's name — Enter the name of the person receiving services.

2. Employer’s name — Enter the name of the individual, who is age 18 or over and does not have a legal guardian or the legally authorized representative.

3. Individual's Identification Number — This is for CDSA use only and allows the CDSA to enter a unique tracking number for each individual.

4. Relationship to the individual — If the CDS employer is not the one receiving services, define the relationship between employer and recipient.

5. Second Landline Phone Information — The CDS Employer provides the second landline number, the name of the person associated with the second landline number, checks whether or not services are delivered on a regular basis, and indicates the reason for the request.

6. Employer Cell Phone Information — The CDS Employer provides the cell phone number, the name of the person associated with the cell phone number, checks whether or not services are delivered in the community on a regular basis, and indicates the reason for the request.

7. Certification — The individual or his legally authorized representative signs and dates the form certifying that the cell phone and landline phones are not those if the CDS Employee.

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