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Effective Date: 
7/2013

Documents

Instructions

Updated: 1/2018

Purpose

To document the employer's (the individual or their legally authorized representative (LAR)) appointment of a designated representative (DR) to perform employer responsibilities in the Consumer Directed Services (CDS) option offered by the individual's program.

To document the financial management services agency's (FMSA's) criminal history results when the DR is a non-relative.

Procedure

When to Prepare

The employer completes this form every time a DR is appointed.

Note: Any previous appointment of a DR is revoked upon the effective date of a change (new appointment). If the employer does not wish to appoint another DR, Form 1721, Revocation of Appointment of a Designated Representative, is completed.

Number of Copies

Original and three copies.

Transmittal

The employer keeps the original on file and gives a copy to the DR and FMSA.

Form Retention

The employer and all parties must keep this form for six years after termination of the appointment or until all outstanding litigation, claims and audits are resolved.

Detailed Instructions

Individual's Name — Enter the name of the individual receiving services.

Medicaid Number — Enter the individual's Medicaid (or other HHSC assigned) number.

Employer Name — Enter the name of the employer.

Relationship to Individual — Check the appropriate box that identifies the employer's relationship to the individual.

Initial or Change — Check the appropriate box that identifies whether the appointment is an initial (first) appointment or if this is a change in appointment.

Designated Representative — The DR prints his or her name, signs the Signature line, enters his or her Social Security number, date of birth, date he or she signs the form and relationship to the individual.

Employer — The employer prints his or her name, signs the Signature line, and enters the date he or she signs the form and relationship to the DR.

Date of DPS Check, Time and Obtained By — The CDS employer gives approval to the FMSA to use the Department of Public Safety (DPS) website to run a criminal conviction check on non-relatives and enter the information on the form. A person is considered to be a relative if the person is related within the fourth degree of consanguinity or within the second degree of affinity. Two people are related to each other by consanguinity if one is a descendant of the other or if they share a common ancestor. An adopted child is considered to be a child of the adoptive parent for this purpose. Two people are related by affinity if they are married to each other or if one person is related by consanguinity to the other person’s spouse. (See Appendix II, Degree of Consanguinity or Affinity, in the Home and Community-based Services (HCS) Program Billing Guidelines, or Appendix VI, Degree of Consanguinity or Affinity, in the Texas Home Living (TxHmL) Program Billing Guidelines.

The FMSA indicates whether or not the person is barred based on convictions listed in Texas Health and Safety Code Section 250.006 (a) or (b), has a criminal history that indicates the person has been convicted of an offense included in §250.006 (b) within the previous five years, and checks the Convictions boxes on the form.

The effective date of this designation is — Enter the effective date of the designation.

The DR is appointed to perform the following employer responsibilities — The employer specifies the responsibilities the DR must perform.

The DR may not perform the following employer responsibilities — The employer specifies the responsibilities the DR must not perform.

Designated Representative — The DR prints his or her name, signs and dates this form.

Employer — The employer prints his or her name, signs and dates this form.