TX HHS Form 1739. Service Provider Agreement

The TX HHS Form 1739, Service Provider Agreement, is a crucial document that facilitates the provision of services to individuals through the Consumer Directed Services (CDS) Option. This agreement is typically used in situations where an individual receives home and community-based support programs, and a service provider is responsible for providing authorized services, items, or goods.

This form requires the service provider to agree to several key conditions, including providing services that are authorized prior to purchase, keeping records of purchased services, and accepting payment from the Financial Management Services Agency (FMSA) in the form of checks. The service provider must also accept that they will not impose additional charges on individuals for services paid for by the FMSA. Additionally, the service provider agrees to provide records and information upon request to the individual, the FMSA, or HHSC.

The agreement is effective as soon as it is signed and terminates when the service provider is no longer providing services through the FMSA. Key points to note include:

• The FMSA will pay the service provider for authorized services in accordance with this agreement and program rules.
• The service provider can charge individuals for approved upgrades or purchases not authorized or paid for by the FMSA.
• The FMSA is responsible for acquiring the completed agreement, retaining the original on behalf of HHSC, and issuing payment once the agreement is received.