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Effective Date: 
10/2013

Documents

Instructions

Updated: 10/2013

Purpose

The purpose of this form is for Consumer Directed Services (CDS) Employers residing in HHSC regions included in Electronic Visit Verification (EVV) to document their choice about EVV participation.

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, Financial Management Services Agencies (FMSAs), and all CDS individuals who receive the following services:

  • 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 (PHC) services 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

The FMSA presents the options for EVV participation to CDS Employers and obtains the CDS Employer's documentation of level of participation:

  • prior to the expansion date for those who reside in the HHSC areas of state in which the EVV is targeted for expansion; or
  • at the time an individual who resides in an EVV region initiates the CDS option.

Number of Copies

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

Transmittal

The FMSA gives a copy of Form 1722 to the individual.

Form Retention

Retain a copy of Form 1722 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 individual’s legally authorized representative.

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

4. Relation to Individual — If the CDS Employer is not the one receiving services, define the relationship between employer and recipient.

5. Level of Participation — The CDS Employer places a check mark for the level of EVV participation selected.

6. Reason — The CDS Employer lists a reason for selecting either partial or no participation in EVV.

The individual or his legally authorized representative signs and dates the form indicating the FMSA has shared the levels of EVV participation and the choice of participation level in EVV.