PURPOSE

To document that the employer has acknowledged the criteria for employer and employee relationships, employer and service provider relationships, and other definitions in Consumer Directed Services (CDS) as part of the service agreement with the Consumer Directed Services Agency (CDSA).

PROCEDURE

When to Prepare

The employer reviews, signs and dates this form as part of the service agreement between the employer and the CDSA. The relationship criteria are reviewed by the employer to ensure that the employer is aware of, and in agreement with, the restrictions on the employer/service provider relationship.

Number of Copies

The original and one copy.

Transmittal

The CDSA retains the original on file with the service agreement. The employer retains a copy with a copy of the service agreement.

Supply Source

This form must be printed or downloaded from the Consumer Directed Services Handbook at: http://www.dads.state.tx.us/handbooks/cds/forms/index.asp

Form Retention

The CDSA and the employer must keep the form for five years after termination of the agreement, or until all outstanding litigation, claims and audits are resolved.

DETAILED INSTRUCTIONS

Certification by Employer and Employee —  The employer and the CDSA representative sign the form to certify that the information and the criteria presented on this form are acknowledged.

The employer must ensure the relationships continue to meet the requirements between the employer, individual, designated representative (if applicable) and each employee and that the relationship(s) do not prevent or change an applicant's or employee's status from being an employee, or change the status of the individual, the employer or other parties in CDS.