Texas Department of Aging and Disability Services
Form 1725, July 2013-E
Criminal Conviction History and Registry Checks
Consumer Directed Services
Applicant is a person being considered as a service provider (employee or independent contractor [when required]).
Section I – Applicant Authorization/Acknowledgment (Applicant must complete this section.)
I, (applicant’s printed name __________________) , give my permission to check for a criminal conviction history, to check the required registries annually, and to check the state and federal lists of individuals and entities excluded from participation in Medicaid (LEIE) monthly as part of my application as a service provider through the Consumer Directed Services (CDS) option. I also understand that a criminal conviction or a registry listing that prohibits a person from employment in a health care setting in the state of Texas may prohibit my employment.
I understand that I must not provide services for payment until the required criminal history and registry checks are conducted, the employer and Financial Management Services Agency (FMSA) review the results and determine that I can be paid for services, and this form is signed by the FMSA.
Signature: ________________________ Applicant Date __________________________
Applicant Information Required by the Texas Department of Public Safety (DPS) (Applicant must print.)
Individual’s Name (Last, First, Middle) ___________________________________________________________________________________
Alias _________________________________________ Maiden Name _______________________________________________________
Date of Birth (mm/dd/yyyy) _____________________________Social Security No. ________________________________________________
Section II – Criminal Conviction History Check and Registry Verification Process (Employer must complete this section.)
Individual’s Name ___________________________________ Employer Name __________________________________________________
Criminal Conviction History Check (Check each box to certify agreement):
___ I request that my FMSA obtain a current Criminal Conviction History Check of the applicant from DPS. I authorize the FMSA to be reimbursed for the cost of obtaining the DPS Criminal Conviction History Check and if I request the report, the cost of sending the report from my budgeted funds.
___ I understand that if I request the report, the FMSA must send it to me through a secure method, DPS approved encrypted software or certified mail.
___ I understand that all criminal records and reports obtained by my FMSA, and the information they contain, are confidential information.
___ I understand all DPS criminal history information reports must be destroyed five days after I make the hiring decision. Paper records need to be shredded, pulped or burned. For electronic records, destroying the media or using specialized software to copy over the data are acceptable methods.
___ I understand that sharing of criminal history information with any person or agency may be prosecuted as a Class A Misdemeanor.
Signature – Employer ____________________________________________ Date _______________________________________________
___ I request that my FMSA obtain the applicant’s status with the Employee Misconduct Registry and the Nurse Aide Registry initially and annually.
___ I understand that the FMSA will screen the applicant initially and monthly using both the state and federal lists of excluded individuals and entities (LEIE).
___ I also understand that the applicant cannot provide services and cannot be paid with program funds until the criminal history and registry checks are completed and my FMSA has notified me that the applicant meets the qualifications.
Signature – Employer _____________________________________________ Date ______________________________________________
I request that the FMSA provide the criminal history to me:
Section III – Criminal Conviction History and Registry Check Results
DPS Criminal Conviction Criminal History Check
Date of DPS Check _____________________________________________________ Time (specify a.m. or p.m.) _________________________ Obtained By __________________________________________________________Convictions: Yes _____ No _____
DPS approved dissemination method used to inform employer of results:
___Did not request report – sent Form 1725
Date FMSA staff notified employer: _______________________FMSA staff: ___________________________________________________ Date disseminated by FMSA: __________________________________________________________________________________________
If yes, does the conviction(s) prohibit service delivery in compliance with Health and Safety Code Chapter 250, §250.006(a), or §250.006(b)? Yes ___ No ___
Within five calendar days after the hiring decision, the FMSA must destroy the criminal history record information obtained from DPS whether or not hired or retained by the employer or designated representative.
Date report was destroyed: _________________________________ Date employer notified FMSA of hiring decision: ________________________
Registry Checks (Call 1-800-452-3934)
Date of Registry Checks ____________________________________ Time (specify a.m. or p.m.) ______________________________________ Obtained By __________________________________________ Employer ________________ FMSA Representative ____________________
Employee Misconduct Registry: ____No Record ____ Record (must not be hired or retained)
Nurse Aide Registry: ____ No Record ____ Record (must not be hired or retained)
Medicaid Exclusion List: ____ No Record ____ Record (must not be hired)
Certification – I acknowledge that the applicant’s DPS criminal conviction history and registry record were checked.
The applicant ___ is ___ is not eligible for hire, to be retained for service delivery based on the checks above.
Signature – FMSA Representative_______________________________ Date FMSA notified the employer or Designated Representative ____________
FMSA and Employer Must Each Keep Original or Copy of This Form