TX HHS Form 1739. Service Provider Agreement

The Texas Health and Human Services (HHS) Form 1739, Service Provider Agreement, is a contractual agreement between the HHS Commission, Financial Management Services Agency (FMSA), and a service provider offering services to individuals through the Consumer Directed Services (CDS) Option. The purpose of this form is to outline the terms and conditions for providing authorized services, items, or goods to individuals in home and community support programs.

This agreement requires the service provider to provide records of purchased services, items, and goods, accept checks from FMSA as full payment, and not impose additional charges on individuals. The FMSA and HHS agree to pay the service provider for authorized services and allow them to charge individuals for approved upgrades or purchases. The form also outlines the responsibilities of the FMSA in acquiring and retaining the original agreement, processing payments, and ensuring that funds are provided by HHS with government funds.

The Service Provider Agreement is effective on the date signed and terminates when the service provider is no longer providing services through the FMSA. The form requires a representative from the service provider or entity to sign, indicating their authorization to negotiate the agreement on behalf of the entity. This document is essential for ensuring compliance with program rules and policy, as well as facilitating payment and record-keeping processes between the service provider, FMSA, and HHS.