Consumer Directed Services



Employer Forms


Documentation of Employer Orientation By CDSA – 1736      (Instructions)

This form is to be used at the end of Orientation. This certifies the training was complete, and the Employer of record was given all the CDS training as far as the Texas Administrative rules (Ch.41), CDS Training manual, and also to certify that the information on the form is correct.

Appointment of a Designated Representative - 1720      (Instructions)
Spanish Version

Form 1720 is used to document the employer's appointment of a designated representative (DR) to perform employer responsibilities in the Consumer-Directed Services (CDS) option offered by the individual's program. The DR cannot be the employee, the spouse of an employee or provide any other Medicaid service to the employer. This form must be provided to the CDSA within two working days after the appointment of the DR.

Revocation of Appointment of Designated Represenative - 1721      (Instructions)
Spanish Version

Any previous appointment of a designated representative (DR) is revoked upon the effective date of a change (new appointment). Form 1721 is used to document when the employer in Consumer-Directed Services (CDS) revokes the previous appointment of a DR to perform employer responsibilities and assumes all employer responsibilities without appointing a new DR.

CDS Rules Acknowledgement – 1738      (Instructions)

Form 1738 documents that the employer in Consumer Directed Services (CDS) is aware that the CDS option is regulated by rules specific to CDS and to the community services program from which the individual or employer receives services. This form is to be signed by the employer at orientation and acknowledges the employer understands all applicable rules and how they are to be followed. If the employer has appointed a designated representative (DR) the are to receive a copy.

Application for EIN – SS-4

Use IRS Form SS-4 to apply for an EIN. An EIN is a nine-digit number (for example, 12-3456789) assigned to the employer for tax filing and reporting purposes. The information provided on this form will establish a business tax account. An EIN is for use in connection with business activities only and should not be used instead of a social security number (SSN).

Change of Address - 8822

Use IRS Form 8822 if you changed your home, business mailing address, or your business location.

Corrective Action Plan - 1741      (Instructions)
Spanish Version

A Corrective Action Plan (CAP) may be requested by the CDSA (related to employer responsibilities), the case manager or service coordinator (related to program issues), or DADS staff (related to CDS or program). Form 1741 is used to document the Corrective Action Plan (CAP) developed by the employer or designated representative (DR).

Acknowledgement of Support Consultation Services Info - 1586      (Instructions)
Spanish Version

Form 1586 is used to provide information to the individual requesting services or the individual receiving ongoing services on the availability of Support Consultation Services in some programs offering the Consumer Directed Services (CDS) option. This form is signed by a TDADS representative and the employer.

Backup Plan - 1740      (Instructions)

Form 1740 is used to document the Service Backup Plan developed by the employer or designated representative (DR). The Backup Plan will include any service that is identified as "critical" to the health, safety or welfare of the individual when normal service delivery is interrupted, in the absence of the regular service provider, or in an emergency.

CDS Option Overview - 1581      (Instructions)
Spanish Version

Form 1581 provides an overview of benefits and responsibilities of the Consumer Directed Services (CDS) option in the Community Care for Aged and Disabled (CCAD) program, the Client Managed Personal Attendant Services (CMPAS) program and all waiver services including Community Based Alternatives (CBA), Community Living Assistance and Support Services (CLASS), Consolidated Waiver Program (CWP), Deaf Blind Multiple Disabilities (DBMD), the Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS) and Texas Home Living Program (TxHmL).

CDS Responsibilities and Consumer Self-Assessment – 1582      (Instructions)
Spanish Version

"Form 1582 provides information to the individual requesting services or the individual receiving ongoing services about the responsibilities assumed if the Consumer Directed Services (CDS) option is available in his program and is selected."

Consumer Participation Choice - 1584      (Instructions)

Form 1584 is used to give the consumer requesting services or the consumer receiving ongoing services the choice of participating in the Consumer Directed Services (CDS) option, the Service Responsibility Option (SRO), or remaining with the provider Agency Option (AO).

Employee Qualification Requirements - 1583      (Instructions)
Spanish Version

Form 1583 provides information to the individual requesting services or the individual receiving ongoing services on additional responsibilities of being an employer in the CDS option offered by their program, and who may or may not be hired in the Consumer Directed Services (CDS).

Employer and CDSA Service Agreement Form – 1735
Spanish Version

Form 1735 is an agreement used between the CDS client and the CDSA to document the terms of the relationship between the two parties as well as the duration of the agreement and how to make any modifications to the agreement.

Relationship Definitions in CDS – 1726      (Instructions)

Form 1726 explains and documents who can and who cannot be the employee under the CDS option.

CDS Rules Acknowledgement – 1738      (Instructions)

Form 1738 documents that the employer in Consumer Directed Services (CDS) is aware that the CDS option is regulated by rules specific to CDS and to the community services program from which the individual or employer receives services. This form is to be signed by the employer at orientation and acknowledges the employer understands all applicable rules and how they are to be followed. If the employer has appointed a designated representative (DR) the are to receive a copy.

Employer-Payer Appointment of Agent - 2678

Use IRS Form 2678 to request approval to have an agent file returns and make deposits or payments of employment or other withholding taxes or to revoke an existing appointment.

Status Report C-1

This report is required of every employment unit and will be used to determine liability under the Texas unemployment Compensation Act. Also see http://www.twc.state.tx.us/ui/tax/c1i.html

Written Authorization C-42

Texas Workforce Commission (TWC) Form C-42 is used to authorize the CDSA to act on behalf of the CDS employer as its lawful representative in its relations with the TWC. Specifically, this form authorizes the CDSA to transact any and all business between the TWC and the CDS employer as if the CDSA were the CDS employer excluding legal court proceedings.

Tax Information Authorization - 8821

The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS for the tax matters listed.



Employee Forms


New Employee Packet Cover Sheet - 1724      (Instructions)

Form 1724 serves as proof that documentation for each applicant hired as an employee has been processed and distributed as required; as a checklist and a cover sheet to the CDS Agency (CDSA) for the documents that must be submitted to the CDSA for each employee and, as a checklist and cover sheet for the personnel file for each new employee that must be maintained by the employer.

Background Verification Form - 1725      (Instructions)

Form 1725 is used to document an applicant's authorization for a required criminal conviction history check and registry checks to be conducted by the applicant, the employer or the Consumer Directed Services Agency (CDSA). It documents the applicant's personal information required to make the checks as well as who will conduct the Texas Department of Public Safety (DPS) criminal conviction history and registry checks. It also documents the results of the checks and if the applicant can be employed or serve as a designated representative (DR) for the CDS client.

Applicant Verification for Employees - 1729      (Instructions)

Form 1729 is used to verify and document the applicant's qualifications and eligibility for employment by the employer for Consumer Directed Services (CDS). This form also serves as the Consumer Directed Services Agency (CDSA) applicant verification form. All applicants must be verified by the CDSA before the CDS employer can hire the applicant. See instructions for employment qualifications.

Service Provider and Employer Certification of Relationship Status for CDS - 1734      (Instructions)

Form 1734 is used to document information regarding the relationship requirements between the employer and the employee. The employer and the employee review the information in this form to ensure that each is aware of allowable relationships and the relationships that are not allowed between all parties in CDS. If any criterion is marked Yes on this form, the employee must not be hired.

I-9 Form

The purpose of this form is to document that each new employee (both citizen and non citizen) are authorized to work in the United States. Employers are required to verify all documentation before hire.

Liability Acknowledgement - 1728      (Instructions)

Form 1728 is used to document the acknowledgment of liability regarding the relationship between the employer and the applicant for employment in the Consumer-Directed Services (CDS) option. It also serves to document that employees are not employed by the Texas Department of Aging and Disability Services (DADS); any other state or federal governmental agency; or by the Consumer-Directed Services Agency (CDSA).

W-4 Form

This form is an Internal Revenue Service form used by an employee to indicate his/her tax situation, like exemptions and martial status, to the employer. The W-4 tells the employer the correct amount of tax to withhold from an employee's paycheck.

Texas Employer New Hire Reporting Form

Purpose of this form is to allow employers to fulfill new hire reporting requirements. Employers are required to keep photocopies or electronic records of all reports submitted.

Wage and Benefits Plan - 1730      (Instructions)

Form 1730 serves as the primary document to record the employee's hourly pay, hourly overtime rate, benefits, payroll deductions and the payroll process/distribution policy. It lets the CDSA know of the optional benefits the employee will have for payroll; describes the documents that must be provided to the CDSA before the end of the employee’s first pay period; documents that the employee is aware of his/her Wage and Benefits Plan; and lets the CDSA and the employee know of changes to the Wage and Benefits Plan for each employee.

Employee Work Schedule and Assigned Tasks - 1731      (Instructions)

Form 1731 is the main document used to record an employee's daily work schedule and assigned tasks and to document any changes to the employee's work schedule, assigned tasks or both. Note: tasks or activities the employee does MUST match those listed on the employer's approved service plan.

Employer and Employee Service Agreement - 1737
Spanish Version

Form 1737 is an agreement between the Employer and the employee. The employee agrees that all information given to the employer is correct (i.e..) Social Security, name, address. The employer agrees: (i.e..) to give employee notice of any changes in hours, schedule, pay-rate. It outlines employer responsibilities, employee responsibilities and responsibilities that both have. The employee cannot provide services before this form is signed.

Service Provider Agreement - 1739      (Instructions)
Spanish Version

Form 1729 is used to document the service provider agreement between Consumer Directed Services Agency (CDSA) on behalf of the Texas Health and Human Services Commission (HHSC), the state Medicaid agency; the Texas Department of Aging and Disability Services (DADS), the state operating agency; and a service provider (employee, contractor, entity, vendor) providing services to one or more individuals through the Consumer Directed Services (CDS) Option.

Management of Service Provider - 1732      (Instructions)

Form 1732 is used to document evaluations, conflict resolution, warnings and other activities that occur in the process of managing and supervising service providers in Consumer Directed Services (CDS).

Occupational Exposure to Blood borne Pathogens - 1727      (Instructions)

Form 1727 is used to inform each employee at time of hire of the federal Occupational Safety and Health Administration (OSHA) Standards related to the Hepatitis B vaccination. It is also used to document the employee's receipt and understanding of the information provided to them regarding the Hepatitis B vaccination, their choice to receive or to decline the Hepatitis B vaccination and finally to document if the employee declines the vaccination.

Acknowledgement of Exemption from Nursing Licensure - 1733      (Instructions)

Form 1733 is used to document that the employer and employee acknowledge that the employer may train and supervise the employee in the delivery of certain tasks and/or services without the involvement of a licensed nurse through Consumer Directed Services (CDS) provided the employee that delivers the services has not been denied licensure.