Learn about the Medicaid 1115 Transformation Waiver Renewal.
For information about COVID-19, call 2-1-1 and select Option 6.
Find a COVID-19 testing site | COVID-19 vaccine | More COVID-19 information
Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
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).
Note: the following programs use Texas Health and Human Services Commission (HHSC) Form 1733 instead of Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services (CDS):
- Community Living Assistance and Support Services (CLASS)
- Deaf Blind with Multiple Disabilities Medicaid Waiver Program (DBMD)
- Medically Dependent Children Program (MDCP)
- STAR+PLUS Home and Community Based Services (HCBS) program
- Home and Community-based Services (HCS)
- Texas Home Living Program (TxHmL)
When to Prepare
The employer completes this form with each new employee at the time of hire.
Number of Copies
Original and one copy.
The employer keeps the original and gives a copy to the employee.
The employer must keep this form while in effect, plus five years after termination of the agreement or until all outstanding litigation, claims and audits are resolved.
The employer reviews all information contained in this form with the employee before services are delivered to the individual.
The employer and the employee acknowledge that each has read and understands the information in this form. Each acknowledges that the employer may choose to train and supervise the employee to deliver the tasks and/or services.
Employee — The employee prints his or her name and signs and dates the form.
Employer — The employer prints his or her name and signs and dates the form.
The employer specifically writes the tasks the employee will perform, with supervision of the employer, instead of a licensed nurse. If the employer is the legally authorized representative (LAR) of the individual or member receiving services, the LAR must check the tasks the employee may perform when the LAR is not present to supervise.