PURPOSE

• To document that the applicant for employment (service provider) and the employer have acknowledged the criteria for the employer and for the service provider (includes employees, contractors and vendors) relationship and other relationships in the Consumer Directed Services (CDS) option.
• To have the applicant/service provider document his eligibility to deliver services to this individual in the CDS option, based on each relationship criterion.
• To determine and acknowledge the service provider's eligibility for service delivery based on the relationship to parties in the CDS option.

PROCEDURE

When to Prepare

The employer and the service provider review the information in this form to ensure that each is aware of allowable relationships and the relationships that are not allowed between applicable parties in CDS. If any criterion is marked Yes on this form, the service provider must not be hired.

Number of Copies

Original and two copies.

Transmittal

The employer retains the original on file and the service provider is given one copy. The second copy is sent to the Consumer Directed Services Agency (CDSA) for validation of the service provider's eligibility for employment.

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

DETAILED INSTRUCTIONS

Initial Information

The employer enters information, as required:

• name of Applicant/Service Provider, including maiden name, if applicable.
• Service Provider's Social Security number.
• name of the Individual receiving services.
• name of the Employer.
• Service Provider's relationship to the Individual receiving services, if applicable.
• name of the Designated Representative (DR), if applicable.
• Service Provider's relationship to the Employer.
• Service Provider's relationship to the DR.

Questionnaire

The service provider enters a check mark in the appropriate box for each question. The service provider or the employer must respond to each question under the "All Programs" section. Refer to Form 1726, Relationship Definitions in Consumer-Directed Services Employer's Acknowledgment and Certification.

• If the individual is enrolled in the Client Managed Personal Assistant Services Program (CMPAS), the spouse may be employed. If the spouse of the individual or of the employer is the service provider, mark the response for each applicable item (6 and 7 only) "N/A" (not applicable).
• If the individual is not with DFPS, mark Items 8 and 9 "N/A."
• If the individual is enrolled in the Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), or Texas Home Living (TxHmL), the questions in that section also must be answered.
• If the individual is enrolled in the Primary Home Care (PHC) Program, Community Attendant Services (CAS) or Family Care (FC), the questions in that section also must be answered.

Employer and Service Provider Certification

The employer must ensure that the service provider is eligible for service delivery for this individual based on the relationship criteria. If any required criterion is marked "Yes," the service provider is not eligible for employment through the CDS option and must not be hired.

The employer must place a check mark in the box in front of either "is" or "is not" eligible for employment.

The employer and the service provider each sign the form to certify that the criteria presented on this form are met or not met, and that the responses are accurate.

Note: If hired, the applicant must have met, and must continue to meet, the relationship criteria.

If there is a change in relationship or status of any party, and the service provider does not continue to meet all relationship criteria, the service provider is prevented from continued service provision, effective the date of the relationship or status change.

When a service provider no longer meets the relationship criteria, the employer must terminate the service provider's employment.