Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 
1/2018

Documents

Instructions

Updated: 1/2018

Purpose

To document when the employer in Consumer Directed Services (CDS) revokes the previous appointment of a designated representative (DR) to perform employer responsibilities and assumes all employer responsibilities without the assistance of a DR.

Procedure

When to Prepare

The employer completes this form when the employer chooses to revoke the appointment of a DR and assumes all employer responsibilities without the use of a DR.

Note: Form 1721 is not completed when there is a change in DR. Form 1720 is completed when there is a change in DR.

Number of Copies

Original and three copies.

Transmittal

Form Retention

The employer keeps the original on file and gives a copy to the DR; to the Financial Management Services Agency (FMSA); and to the individual's case manager/service coordinator.

Detailed Instructions

Individual/Member Name — Enter the name of the individual or member receiving services.

Medicaid Number — Enter the individual's or member's Medicaid (or other HHSC assigned) number.

Employer Name — Enter the name of the employer.

Relationship to Individual/Member —  Check the appropriate box that identifies the employer's relationship to the individual or member.

Revocation Effective Date — Enter the date the employer will assume all responsibilities of primary contact and decision maker for CDS.

Employer — The employer prints his or her name, signs and dates this form.

Witness — The witness prints, signs and dates this form. A witness must be 18 years of age or older.