Form 1721, Revocation of Appointment of Designated Representative

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.