Effective Date
Instructions
Updated: 5/2026
Purpose
To document the employer’s acknowledgment of the criteria for employer and employee relationships, employer and service provider relationships, and other definitions in Consumer Directed Services (CDS) as part of the service agreement with the financial management services agency (FMSA).
Procedure
When to Prepare
The employer reviews, signs and dates this form as part of the service agreement between the employer and the FMSA. The employer reviews the relationship criteria to make sure they are aware of, and in agreement with, the restrictions on the employer and service provider relationship.
Number of Copies
Original and one copy.
Transmittal
The FMSA keeps the original or copy on file with the service agreement. The employer keeps the original or copy with a copy of the service agreement.
Form Retention
The FMSA and the employer must keep the form for five years after termination of the agreement, or until all outstanding litigation, claims or audits are resolved.
Detailed Instructions
Employer’s Acknowledgement and Certification — The employer and the FMSA representative sign the form to certify acknowledgement of the information and requirements presented on the form.
The employer must make sure the relationships between the employer, person, designated representative, if applicable, and each employee continue to meet these requirements.