- To verify that documentation for each applicant hired as an employee has been processed and distributed as required for Consumer Directed Services (CDS).
- To serve as a checklist and a cover sheet to the Financial Management Services Agency (FMSA) for the documents that must be submitted to the FMSA for each employee.
- To serve as a checklist and a cover sheet for the personnel file for each new employee that must be maintained by the employer.
When to Prepare
The employer must complete this form with each applicant at the time of hire.
Number of Copies
The original and one copy.
The employer keeps the original or a copy in the employee's personnel file. The employer submits the original or a copy to the FMSA with required documents and forms attached.
The employer must keep this form while in effect, plus five years after termination of the employment or until resolution of all outstanding litigation, claims and audits.
Name of Individual Receiving Services — Enter the name of the individual receiving services.
Employer Name — Enter the name of the employer.
Employee Name — Enter the name of the employee.
Date of Hire — Enter the employee's date of hire.
First Day of Work — Enter the date of the first day that the employee is scheduled to work.
The employer must verify that each document or form is completed for the employer and for the FMSA. The employer must enter a check mark in each box, where applicable.
Documents and forms listed with a filled block in the FMSA column are not copied to the FMSA. The document or form must be completed by the employee and retained in the personnel file.
The employer must ensure that the original or a copy of each document or form is valid and is maintained in the employee's personnel file for the employee. The employer must ensure that the original or a copy of each document or form is provided to the FMSA.
The employer uses this form as a checklist to ensure that each required document and form is completed. The employer uses this form as a cover sheet for the documents and forms for the personnel file and for transmittal to the FMSA.
Document Description / Form Information
Each document or form listed on this form must be completed before the employee begins work. The employer must verify that the employee has completed each document and form accurately and according to instructions.
The FMSA must verify each employee's qualifications before the individual is hired by the employer. An individual not qualified to provide the service must not be paid by the FMSA. An employee will not receive payment for services until the FMSA has received all required documents and has verified the individual's eligibility for employment.
The agency column identifies the federal or state governmental agency that provides the document or form and/or that requires completion of the item. Refer to the legend at the bottom of the form for agency initials and names.
The employer must document the employee’s initial orientation, annual evaluations, and training or job performance issues on HHSC Form 1732, Management and Training of Service Providers. The employer must send the original or a copy of this form to the FMSA within 30 calendar days of an initial orientation or annual evaluation and when an action affects the service provider’s continued status with the employer (e.g., termination).
The employer must review and approve by signature/date each of the documents as received from the employee (time sheets and receipts) or a vendor (invoices).
The employer retains the original or a copy of an employee's time sheets and receipts on file in the employee's personnel file and submits the original or a copy to the FMSA for processing. Each time sheet must be received by the FMSA by the due date to ensure timely payment of payroll.
The FMSA must reimburse receipts for the employee or the employer within 30 days of receipt by the FMSA. The employer must approve each receipt before the FMSA will process it; the expense must be allowable, reasonable and budgeted before purchase for payment is made.
The FMSA must reimburse invoices from the employer's vendors (out-of-home respite providers, administrative purchases, etc.) within 30 days of receipt by the FMSA. The employer must approve each invoice before the FMSA will process it; the expense must be allowable, reasonable and budgeted before purchase for payment is made.
The cover sheet/checklist does not need to be checked for Ongoing Documentation. The ongoing section serves as a reminder to the employer of documentation and forms that must be processed for each employee.
Additional Information and Resources
|Texas Health and Human Services Commission (HHSC)
|HHSC Form 1725, Criminal Conviction History and Registry Checks
|United States Citizenship and Immigration Services (USCIS)
|USCIS Form I-9, Employment Eligibility Verification: Do not submit copies of documents to the FMSA, only Form I-9. Must verify that each document used to verify the employee's employment eligibility is renewed prior to its expiration date.
|State of Texas, Office of the Attorney General (OAG)
|Texas Employer New Hire Reporting Form (within 20 days of hire): Recommended that reporting be made at time of hire. (The OAG transmits the report to the National Directory of New Hires.)
|United States Internal Revenue Service (IRS)
|IRS Form W-4, Employee's Withholding Allowance Certificate: Must be provided to the FMSA before first payroll check is calculated.
|HHSC Form 1729, Applicant Verification for Employees; age, relationship, CPR, and driver's license and insurance (if applicable); initial orientation
|HHSC Form 1730, Wage and Benefits Plan Employee Compensation