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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 to request to use the CDS Employer's cell phone number or to request additional phone numbers for the Electronic Visit Verification (EVV) system.

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

If the CDS Employer requests to use a cell phone or requests to use a second landline for the EVV system, the FMSA sends this form to the CDS individual for completion and submittal to the FMSA.

Number of Copies

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

Transmittal

The FMSA gives a copy of Form 1723 to the individual.

Form Retention

The FMSA retains a copy of Form 1723 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. Employer Relation to Individual — If the CDS Employer is not the one receiving services, define the relationship between employer and recipient.

5. Second Landline Phone Information — The CDS Employer provides the second landline number, the name of the person associated with the second landline number and that person’s relationship to the individual, checks whether or not services are delivered at the second landline phone location on a regular basis, and indicates the reason for the request.

6. Employer’s Cell Phone Number Information — The CDS Employer provides the cell phone number, checks whether the individual routinely receives services outside the home, checks whether or not the individual has a landline phone, checks whether the individual does not want to make the landline phone available, and indicates the reason for the request.

7. Employer Certification — The individual or his legally authorized representative signs and dates the form certifying that the cell and landline phones are not those of the CDS Employee.