Form 1749, Employer and Entity Service Agreement

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Documents

Effective Date: 1/2018

Instructions

Updated: 1/2018

Purpose

To document the service agreement between a Consumer Directed Services (CDS) employer and an entity providing services to an individual. Examples of agreements with entities include purchasing backup plan services from a Home and Community Support Services Agency (HCSSA) or a nursing assessment from a licensed home health agency or a certified Home and Community based Services (HCS) or Texas Home Living (TxHmL) provider.

Procedure

When to Prepare

An employer or designated representative (DR) must, before an entity provides services to an individual, ensure required Texas Health and Human Services Commission (HHSC) service agreements with signatures have been completed between the employer and the contractor. Form 1739, Service Provider Agreement, must be completed for each contractor paid through the Financial Management Services Agency (FMSA) for one or more individuals participating in the CDS option.

Notes:

  • The FMSA must approve the contractor’s eligibility, in writing, to the employer. Services provided before the contractor'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 contractor until after the contractor has signed the service agreement and the FMSA has received the signed service agreement.

Number of Copies

Original and at least one copy.

Transmittal

The employer or DR must retain the original in its file for the contractor. A copy is provided to the contractor and the FMSA by the employer or DR.

Detailed Instructions

The individual and contractor are responsible for completion and processing of this form.

The name of the person receiving services, hereafter referred to as the “Individual,” is  — Enter the name of the individual receiving services.

The Individual’s program . . .  — Enter the individual’s specified program.

The Contractor is — Enter the name of the contractor.

Authorized Program Service — Enter the authorized program service(s).

Service Plan Authorization Dates — Enter the start and end dates for each service the contractor agrees to provide.

Unit Rate of Pay — Enter the unit rate of pay for each service.

No. of Units — Enter the number of units to be purchased for each service.

Total — Enter the total.

Printed Name, Signature and Date — The individual and contractor must both sign and date Form 1749/Form 1749-S.