Employer'S Selection For Electronic Visit Verification (Form 1722) - Texas

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Form 1722
October 2013-E
Employer's Selection for Electronic Visit Verification (EVV)
EVV is a telephone and computer-based system that documents the time your attendant starts and ends delivering services to you. This form
is to be completed by Consumer Directed Services (CDS) Employers in EVV regions. The CDS Employer keeps a copy and sends the original
to the Financial Management Services Agency (FMSA).
For FMSA Use Only
1. Individual's Name
3. Individual's Identification Number
4. Relation to Individual
2. Employer's Name (if different from the individual)
5. My FMSA has explained my options for using EVV. I am selecting:
Full Participation: My CDS Employee(s) will call-in when they start work and call-out when they end work. I will use the computer to
do Visit Maintenance.
Partial Participation: My CDS Employee(s) will call-in when they start work and call-out when they end work. My CDS Employee(s)
will continue using paper time sheets. I will send the paper time sheets to my FMSA. My FMSA will do Visit Maintenance to make the
EVV system match the paper time sheets.
No EVV Participation: My CDS Employee(s) will continue using paper time sheets. I will approve the paper time sheets and send
them to my FMSA to pay my employees.
6. Reason:
Signature — CDS Employer
Date
Signature — FMSA Representative
Date

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