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Effective Date: 



Updated: 7-2013


To provide a statement of agreement or disagreement for the Community Attendant Services (CAS) annual service plan reauthorization through the Consumer Directed Services (CDS) option.


When to Prepare

The form is provided to the CDS individual or employer of record to indicate agreement or disagreement with the annualized service plan through CAS.

Number of Copies

The Texas Health and Human Services Commission (HHSC) case manager retains a copy in the individual's file and sends a copy to the HHSC regional nurse. The individual/employer of record may keep a copy for his records.


The HHSC case manager sends the form with the annualized service plan (Form 2101, Authorization for Community Care Services) to the individual/employer of record for a signature. The individual/employer of record must sign and date the form and return it to the HHSC case manager within 14 calendar days. The form may be faxed, mailed or hand delivered.

Form Retention

The form is kept in the case record for three years after the case is closed.

Detailed Instructions

The case manager completes the identifying information on the top of the form and enters the individual’s name, identification number, address and telephone/fax number before sending the form to the individual.

Employer of Record Statement of Agreement – The individual/employer of record reviews the annualized service plan and indicates on the form if he agrees with the plan by checking the box and signing and dating the form. The annualized plan has been developed with the individual/employer of record during the annual reassessment.

Disagreement – If the individual/employer of record disagrees with the annualized service plan, he checks the box and must provide the reason for his disagreement. He signs and dates the form.

Contact Information The case manager completes the contact information by entering his name, address, telephone number and fax number before sending the form to the individual.

Within 14 days of receipt, please sign and return this form to the case manager by fax or mail Provides instructions to the individual/employer of record to return the form.