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Effective Date: 
8/2018

Documents


Instructions

Updated: 8/2018

Note: These instructions are also used with Form 1735-S (Spanish) and the following addendums:

  • Form 1735-CFC, Service Provision Requirements Addendum — Community First Choice (CFC), and Form 1735-CFC-S (Spanish)
  • Form 1735-CLASS, Service Provision Requirements Addendum — Community Living Assistance and Support Services (CLASS), and Form 1735-CLASS-S (Spanish)
  • Form 1735-DBMD, Service Provision Requirements Addendum — Deaf Blind with Multiple Disabilities (DBMD), and Form 1735-DBMD-S (Spanish)
  • Form 1735-HCS, Service Provision Requirements Addendum — Home and Community-based Services (HCS), and Form 1735-HCS-S (Spanish)
  • Form 1735-MDCP, Service Provision Requirements Addendum — Medically Dependent Children Program (MDCP), and Form 1735-MDCP-S (Spanish)
  • Form 1735-PCS, Service Provision Requirements Addendum — Health and Human Services Commission (HHSC) Personal Care Services (PCS), and Form 1735-PCS-S (Spanish)
  • Form 1735-PHC, Service Provision Requirements Addendum — Primary Home Care (PHC) Services, Community Attendant Services (CAS) and Family Care (FC), and Form 1735-PHC-S (Spanish)
  • Form 1735-SP, Service Provision Requirements Addendum — STAR PLUS Home and Community Based Services (HCBS) Program, and Form 1735-SP-S (Spanish)
  • Form 1735-TxHmL, Service Provision Requirements Addendum — Texas Home Living (TxHmL), and Form 1735-TxHmL-S (Spanish)

Purpose

To document the separate and mutual responsibilities of the employer and the financial management services agency (FMSA) in using the Consumer Directed Services (CDS) option.

To provide program specific information about the services that can be self-directed, the provider qualifications, service delivery documentation and training requirements.

Procedure

When to Prepare

The employer and FMSA complete Form 1735 or Form 1735-S and the applicable addendum (Form 1735-CFC, Form 1735-CFC-S, Form 1735-CLASS, Form 1735-CLASS-S, Form 1735-DBMD, Form 1735-DBMD-S, Form 1735-HCS, Form 1735-HCS-S, Form 1735-MDCP, Form 1735-MDCP-S, Form 1735-PCS, Form 1735-PCS-S, Form 1735-PHC, Form 1735-PHC-S, Form 1735-S, Form 1735-SP, Form 1735-TxHmL, Form 1735-TxHmL-S):

  • at the CDS orientation when enrolling in the CDS option;
  • any time the employer changes FMSAs;
  • if there is change in employer, such as an individual turning age 18; and
  • if the individual changes programs.

Number of Copies

Original and two copies.

Transmittal

The employer keeps a copy on file and provides a copy to the FMSA.

Form Retention

The employer and all parties must keep the form and addendum for six years after signing the form and addendum, or until resolution of all outstanding litigation, claims and audits.

Detailed Instructions

Initial Information

The name of the individual receiving services — Enter the individual’s name.

The Individual’s community-based services program is — Enter the name of the program.

The name of the employer is — Enter the name of the employer.

The employer is the — Check the box that applies: individual, parent of a minor, or court-appointed guardian of the Individual.

This Agreement is between the Employer and — Enter the FMSA name and the city in Texas where the FMSA is located.

The FMSA has a contract to provide financial management services with — Check the box that applies: HHSC or a managed care organization (MCO).

The Employer agrees to each of the following requirements — The CDS employer must initial each item listed (numbers 1-14) and enter the name of the program in number 6.

Acknowledgement of Service Agreement — The employer prints his or her name, signs and dates the form. The FMSA representative prints his or her name, signs, dates the form and enters the FMSA contract number.

ADDENDUM INSTRUCTIONS (Form 1735-CFC, Form 1735-CFC-S, Form 1735-CLASS, Form 1735-CLASS-S, Form 1735-DBMD, Form 1735-DBMD-S, Form 1735-HCS, Form 1735-HCS-S, Form 1735-MDCP, Form 1735-MDCP-S, Form 1735-PCS, Form 1735-PCS-S, Form 1735-PHC, Form 1735-PHC-S, Form 1735-SP, Form 1735-SP-S, Form 1735-SP, Form 1735-SP-S, Form 1735-TxHmL and Form 1735-TxHmL-S)

The employer agrees to each service provision — The CDS employer or designated representative must initial each provision listed on the addendum.

Employer or Designated Representative Signature and Date — The employer or designated representative signs and dates the last page of the addendum.