In Home Attendant Services

            In home, where you're the boss!

In Home Attendant Services, Ltd.  

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Employee Forms
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Employer Forms




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Employee Forms

* 1724 New Employee Packet Coversheet:
This coversheet is used as a check off list to make sure the ER and the CDSA have a copy of all the correct forms needed.

* 1725 Texas Department of Public Safety (DPS) Criminal Conviction History check:
This form is used for the Employer and Employee to complete before any one is hired. The Employer and the Agency need make sure the employee does not have a felony, misdemeanor, Employee misconduct registry, Nurse aide registry, and Medicaid exclusion.

* 1729 Applicant Verification:
The employer must verify that the applicant meets each criterion. The employer must ensure the following forms and/or copies of documentation to verify the criteria are met and kept in the employee’s personnel file. CDSA also needs a copy of form to verify applicant can be hired.

* 1734 Service Provider and Employer Certification of Relationship Status for CDS:
This form is to verify the relationship between the Employer/ Client and Employee. If any of these boxes are checked off as yes the employee that can not be hired. The employer and the service provider certify that the responses are accurate.

* I-9 Employment Eligibility Verification:
The purpose of this form is to document that each new employee (both citizen and non citizen) are authorized to work in the United States. Employers are required to verify all documentation before hire.

* 1728 Liability Acknowledgement:
The employer is solely responsible and liable for any negligent acts or omissions by the employer: the employee: other employees or service provider: the individual receiving services, or if applicable, the Designated Representative. Employees or Service providers are not employed by the Texas Department of Aging and Disability Services (dads): any other state or federal government agency: or by the Consumer Direct Services Agency.

* W-4 Form:
Purpose of this form is so that your employer can withhold the correct federal income tax from your pay. Consider completing a new W-4 form each year and when your personal or financial situation changes.  Available in 
(english)  or  

* Texas Employer New Hire Reporting Form:
Purpose of this form is to allow employers to fulfill new hire reporting requirements. Employers are required to keep photocopies or electronic records of all reports submitted.  

* 1730 Wage and Benefits Plan:
Employee and employer agree to the compensation, benefits, withholdings and all information above and agree that any changes or revisions must be documented and provided to the employee, the employer and the Consumer Direct Services Agency.

* 1731 Employee Work Schedule and Assigned Tasks:
This is an agreement for the employee and employer that assigned tasks and schedule will be performed.

* 1737 Employer and Employee Service Agreement:
This is an agreement between the Employer and the employee. The employee agrees that all information given to the employer is correct (ie.) Social Security, name, address. The employer agrees: (ie.) to give employee notice of any changes in hours, schedule, pay-rate.

* 1739 Service Provider Agreement:
This agreement is between the Texas Health and Human Services Commission (HHSC), the state Medicaid agency; the Texas Department of Aging and Disability Services (DADS), the state operating agency: a Consumer Direct Services Agency (CDSA) and a service provider.

* 1732 Management of Service Provider:
Purpose of form is to evaluate an employee on their performance. This can be done every 30 days, 3months, 6 months, and or Annual. This form must be completed at least once a year.

* 1727 Occupational Exposure to Bloodborne Pathogens:
All employers are required to make the Hepatitis B vaccine and vaccination available to all employees who have exposure. The cost for the vaccinations is an administrative expense to the employer and is reimbursable through the consumers budget.

* Notice to employees concerning workers compensation in Texas:
As an Employee of a non-covered employer, the employee is not eligible to receive workers compensation benefits under the Texas Workers Compensation Act.

* 1733 Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services delivered through Consumer Direct Services:
The employer may choose to have certain nursing services provided by an unlicensed person employed in the CDS option. The Employer must be able to train the unlicensed employee in the performance of the task and train and supervise the employee performing the tasks. The employee who delivers the service must not have been denied a license.

Employer Forms

* 1736 Documentation of Employer Orientation by Consumer Directed Services Agency-
This form is to be used at the end of Orientation. This certifies the training was complete, and the Employer of record was given all the CDS training as far as the Texas Administrative rules (Ch.41), CDS Training manual, and also certify the information on the form is correct.

* 1720 Appointment of a Designated Represenative-
To document the employer's (the individual or their legally authorized representative) appointment of a designated representative (DR) to perform employer responsibilities in the Consumer-Directed Services (CDS) option offered by the individual's program.

* 1721 Revocation of Appointment of Designated Represenative-
Any previous appointment of a DR is revoked upon the effective date of a change (new appointment). If the employer does not wish to appoint another DR, Form 1721, Revocation of Appointment of a Designated Representative, is completed. The employer keeps the original on file and gives a copy to the DR, the consumer-directed services agency (CDSA) and the individual's case manager/service coordinator.

* 1725 Criminal Conviction History and Registry Checks-
This form is used for the Employer and Employee and/or Designated Representative (DR) to complete before any one is hired. The Employer and the Agency need make sure the employee does not have a felony, misdemeanor, Employee misconduct registry, Nurse aide registry, and Medicaid exclusion.

* Agreement to Forward-
An agreement to forward to my Consumer Directed Services agency (In Home Attendant Services, LTD) all correspondence from Internal Revenue (IRS) and Texas Workforce Commission (TWC) regarding employment of Attendants in the Consumer Directed Services Option.

* Emergency & Other contact information-
This form is to be completed by the Employer of record with Family, friends, neighbors, and hospital numbers. The Employer must have form somewhere in the home were the provider can have access to in case of an Emergency.

* SS-4 Application for Employer Identification number- I
s used to apply for a Federal Identification number.

* 8822 Change of Address-
You can use form 8822 to notify the Internal Revenue Service if you changed your home or business mailing address or your business location.

* 2678 Employer/Payer Appointment of Agent-
This form is used if you want to request approval to have an agent (In home attendant Services, LTD.) file return and make deposits or payments of employment or other withholdings taxes.

* C-1 Status Report-
This report is required of every employment unit, and will be used to determine liability under the Texas unemployment Compensation Act. Also see

* C-42 Written Authorization-
The CDSA must have an Employer Registration Identification Number assigned by TWC as verification that the registration process for the CDSA to represent the CDS employer has been completed.

* 8821 Tax Information Authorization-
The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS for the tax matters listed.

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