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Effective Date: 
8/2015

Documents

Instructions

Updated: 11/2014

Purpose

To document the employer’s acknowledgment of the criteria for employer and employee relationships, employer and service provider relationships, and other definitions in Consumer Directed Services (CDS) as part of the service agreement with the Financial Management Services Agency (FMSA).

Procedure

When to Prepare

The employer reviews, signs and dates this form as part of the service agreement between the employer and the FMSA. The employer reviews the relationship criteria to ensure the employer is aware of, and in agreement with, the restrictions on the employer/service provider relationship.

Number of Copies

Original and one copy.

Transmittal

The FMSA keeps the original or copy on file with the service agreement. The employer keeps the original or copy with a copy of the service agreement.

Form Retention

The FMSA and the employer must keep the form for five years after termination of the agreement, or until resolution of all outstanding litigation, claims and audits.

Detailed Instructions

Certification by Employer and FMSA Representative — The employer and the FMSA representative sign the form to certify acknowledgement of the information and criteria presented on the form.

The employer must ensure the relationships between the employer, individual, designated representative (if applicable) and each employee continue to meet the requirements and that the relationships do not prevent or change an applicant's or employee's status from being an employee, or change the status of the individual, the employer or other parties in CDS.