TX HHS Form 1725. Criminal Conviction History and Registry Checks

Form 1725 is an official authorization and verification document used in the Texas Consumer Directed Services (CDS) option to document criminal conviction history checks and required registry screenings for individuals under consideration for hire as service providers. The form ensures that applicants meet state eligibility standards before they are allowed to begin providing and being paid for CDS services.

Purpose of Form 1725

The purpose of Form 1725 is to formally document that all required background checks have been requested, completed, reviewed, and handled correctly before a CDS applicant is hired. It creates a clear compliance record showing that criminal history and registry screenings were conducted in accordance with Texas law.

The form protects CDS employers, Financial Management Services Agencies (FMSAs), and program participants by ensuring that individuals who are legally prohibited from working in health care settings are not allowed to provide services.

When This Form Is Required

Form 1725 must be used in the following situations:

• Before hiring a new CDS employee or, when required, an independent contractor
• Before an applicant begins delivering services or receiving payment
• When conducting initial and required ongoing registry checks

The form is not required for individuals who are not being considered for hire as CDS service providers or for roles outside the CDS option.

Who Is Authorized to Complete the Form

Form 1725 is completed by multiple parties:

• The applicant completes and signs Section I
• The CDS employer completes and signs Section II
• The Financial Management Services Agency (FMSA) completes Section III and certifies results

Each party has a defined role, and missing signatures or incomplete sections can invalidate the form.

Explanation of Each Key Section

Section I – Applicant Authorization and Acknowledgment

This section documents the applicant’s written consent to criminal conviction history checks, registry screenings, and Medicaid exclusion list monitoring. The applicant acknowledges that certain convictions or registry listings may legally prohibit employment in Texas health care settings.

Applicants must also provide identifying information required by the Texas Department of Public Safety (DPS), including full legal name, date of birth, Social Security number, and signature.

Section II – Employer Request and Certification

In this section, the CDS employer formally requests that the FMSA obtain a DPS criminal conviction history check and required registry screenings. The employer also acknowledges:

• Responsibility for reimbursing DPS-related costs
• Confidentiality requirements for criminal history information
• Restrictions on sharing criminal history data
• Mandatory destruction of criminal history records within five days of the hiring decision

The employer must also select how they wish to receive criminal history results, using approved secure methods.

Registry Check Authorization

This part confirms the employer’s request for initial and ongoing checks of:

• Employee Misconduct Registry
• Nurse Aide Registry
• State and federal Medicaid exclusion lists (LEIE)

Applicants may not provide services or be paid until all checks are completed and cleared.

Section III – FMSA Results and Certification

The FMSA documents when checks were completed, whether convictions or registry records were found, how results were communicated, and whether any findings prohibit service delivery under Texas law.

This section also records compliance with mandatory destruction of criminal history records and certification of eligibility or ineligibility for hire.

Practical Tips for Completing Form 1725

• Ensure the applicant completes Section I fully and legibly.
• Do not allow services to begin before written clearance is confirmed.
• Use only approved secure methods to receive criminal history results.
• Track deadlines for record destruction carefully.
• Retain copies of the completed form as required.

Common Mistakes to Avoid

• Allowing an applicant to work before checks are completed
• Missing applicant or employer signatures
• Improper storage or sharing of criminal history information
• Failing to destroy records within required timeframes
• Assuming registry checks are optional

Legal and Regulatory Context

Form 1725 is required under Texas Health and Safety Code Chapter 250 and related regulations governing criminal background checks in health care settings. Texas law strictly limits who may work in roles involving vulnerable populations and imposes penalties for improper handling or disclosure of criminal history information.

Failure to comply with these requirements may result in criminal penalties, loss of program eligibility, and payment recoupment.

Real-Life Situations Where This Form Is Used

• A CDS employer wants to hire a new personal attendant.
• An existing CDS worker is being re-screened as required.
• An applicant transitions into a role that requires registry checks.

Documents Commonly Associated with This Form

• CDS service provider hiring documentation
• Applicant identification records
• FMSA qualification check records
• Registry screening confirmations

Frequently Asked Questions

Can an applicant start working before checks are complete?

No. Services may not begin until all checks are cleared.

Who reviews the background check results?

The CDS employer and the FMSA review results together.

How often are registry checks conducted?

Initially and then at required ongoing intervals.

What happens if a conviction is found?

Eligibility is determined based on Texas law.

How long are criminal history records kept?

They must be destroyed within five days of the hiring decision.

Is the form required for independent contractors?

Yes, when required under CDS rules.

Related Forms

• CDS Employer Responsibilities Forms
• FMSA Qualification Check Documentation
• Employee Misconduct Registry Forms
• Medicaid Exclusion Screening Records

Form Details

• Form Name: Criminal Conviction History and Registry Checks
• Form Number: 1725
• Program: Consumer Directed Services (CDS)
• State: Texas
• Revision Date: March 2023