Form 1739, Service Provider Agreement

Effective Date
10/2013
Document
Document
1739.pdf (108.7 KB)
Document
Document
1739-S.pdf (108.69 KB)

Instructions

Updated: 10/2013

Purpose

To document the service provider agreement between a Financial Management Services Agency (FMSA) on behalf of the Texas Health and Human Services Commission (HHSC), the state Medicaid agency; and a service provider (employee, contractor, entity or vendor) providing services to one or more individuals through the Consumer Directed Services (CDS) option.

Procedure

When to Prepare

The employer or designated representative (DR) must assist the FMSA in obtaining the required HHSC service agreement form with signatures from each service provider (employee, contractor, entity or vendor), if required by HHSC. A service provider agreement form must be completed for each service provider paid through the FMSA for one or more individuals participating in the CDS option.

Notes:

  • The FMSA must approve the service provider's eligibility, in writing, to the employer. Services provided before the service provider's eligibility is approved, in writing, by the FMSA will not be paid by the FMSA.
  • The FMSA must not pay for eligible services delivered by an eligible service provider until after the service provider (individual, contractor, entity or vendor) has signed the service provider agreement and the FMSA has received the signed service provider agreement.

Number of Copies

Original and at least one copy.

Transmittal

The FMSA must retain the original in its file for the service provider. A copy is provided to the service provider by the FMSA.

Form Retention

The FMSA and the service provider keep this form while in effect and for five years thereafter.

Detailed Instructions

The FMSA and the service provider are responsible for completion and processing of this form.

Service Provider  Enter the name of the service provider and contact information. If the service provider is an entity, enter the name and contact information for the entity.

FMSA  Enter the FMSA name and the city/state information.

Agreement Effective Date  Enter the effective date of the service provider agreement.

Signatures/Dates  The service provider and the FMSA representative must both sign and date the service provider agreement.