Effective Date
Instructions
Updated: 5/2026
Purpose
- To document the service provider’s and employer’s acknowledgment of the relationship requirements for employers and service providers, including employees, contractors and vendors, and others who participate in or support the person using the Consumer Directed Services (CDS) option.
- To have the service provider document their eligibility to deliver services to the person using the CDS option based on each relationship criterion.
- To determine and acknowledge the service provider's eligibility to deliver services based on the service provider's relationship to the person, the employer or others supporting the person using the CDS option.
Procedure
When to Prepare
The employer and service provider review the information on this form to make sure each party is aware of the allowed and disallowed relationships between those who use and participate in CDS. If any criterion is marked Yes on this form, the employer must not hire the service provider.
Number of Copies
Original and two copies.
Transmittal
The employer keeps the original or a copy on file and gives the service provider a copy. The employer sends the original or a copy to the financial management services agency (FMSA) to verify the service provider's eligibility for employment.
Supply Source
Form Retention
The employer and the FMSA must keep this form for five years after termination of the agreement, or until all outstanding litigation, claims or audits are resolved.
Detailed Instructions
Section 1 – Service Provider Applicant's Information
The employer enters the following required information:
- Service provider’s name, including maiden name if applicable
- Name of the person receiving services
- Employer’s name
- Service provider's relationship to the person receiving services
- Name of the designated representative (DR), if applicable
- Service provider's relationship to the employer
- Service provider's relationship to the DR
Sections 2 – 5:
The service provider checks the appropriate box for each question. Review Form 1726, Relationship Definitions in Consumer Directed Services Employer's Acknowledgment and Certification for relationship definitions.
Notes:
- If the person is enrolled in the Consumer Managed Personal Attendant Services (CMPAS) program, the spouse may be employed. CMPAS Service providers should check Not applicable for questions 4 and 5.
- If the person is not a Texas Department of Family and Protective Services (DFPS) foster child or adult, check Not applicable for questions 6 and 7.
- If the person is enrolled in the Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS) or Primary Home Care (PHC), the service provider must also respond to the questions in each of those sections, as applicable.
Employer and Service Provider Applicant Verification
The employer must make sure the service provider is eligible to deliver services to the person based on the relationship requirements. If any criterion is marked Yes, the service provider is not eligible for employment through the CDS option and must not be hired.
The employer must check the appropriate box to indicate if the service provider is or is not eligible for employment.
The employer and service provider each sign the form to certify the service provider meets or does not meet the requirements and the responses are accurate.
Note: If hired, the applicant must have met, and must continue to meet, the relationship criteria.
If there is a change in relationship or status of any party that results in the service provider no longer meeting all relationship criteria, the service provider cannot continue delivering services effective the date of the relationship or status change.
When a service provider no longer meets the relationship criteria, the employer must terminate the service provider's employment.