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Effective Date: 
1/2018

Documents

Instructions

Updated: 1/2018

Purpose

To document that the financial management services agency (FMSA) provided the required orientation training to the employer before the individual or member began using the Consumer Directed Services (CDS) option. The FMSA is required to conduct a CDS orientation when an individual or member transfers from one FMSA to another only if the current employer has not received an initial orientation from an FMSA.

Procedure

When to Prepare

The employer and FMSA complete Form 1736 at the end of the required orientation training. The employer signs this form to certify that the FMSA conducted the training and covered the required topics.

Number of Copies

One copy for the FMSA and one copy for the employer.

Transmittal

The employer retains a copy on file, and the FMSA retains a copy. If there is a designated representative (DR), the employer provides a copy of the form to the DR.

Form Retention

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

Detailed Instructions

Initial Information

The employer enters the following information, as required:

  • Individual/Member Name — Name of the individual or member receiving services.
  • Program Name — Name of the community-based services program from which the individual receives services.
  • Employer Name — Name of the employer.
  • Relationship to Individual/Member — The employer's relationship to the individual or member.

FMSA Contact Information

The FMSA enters the following information:

  • Contact Person Name of the FMSA contact person.
  • Telephone Number/Fax Number — Telephone and fax numbers of the FMSA.

Orientation Location

The FMSA enters the individual's or member's residential address where the employer orientation training is held. Note: The orientation must be held at the individual's residence.

Training Session

The FMSA enters the following information:

  • FMSA Representative Name — Name of the FMSA representative conducting the orientation.
  • Begin Date/Time, End Date/Time, Length of Training Session — Begin and end dates and times for the employer orientation training, as well as the length of the training session in hours/minutes.

Topics Covered

The employer checks each topic covered during the orientation.

Certification

The employer, the FMSA representative and others in attendance sign and date this form certifying that the employer orientation training was completed as required.