Form 1721, Revocation of Appointment of Designated Representative

Effective Date: 1/2007

Availability

PDF: 1721.pdf

Instructions

Updated: 10/2013

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

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.

Supply Source

http://www.dads.state.tx.us/handbooks/cds/forms/index.asp

Form Retention

The employer must keep this form for five years after termination of the agreement, or until all outstanding litigation, claims and audits are resolved.

Detailed Instructions

Individual's Name — Enter the name of the individual receiving services.

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

Employer Name — Enter the name of the employer.

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

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/her name, signs and dates this form.

Witness — The witness prints, signs and dates this form. A witness must be an adult (a person 18 years of age or older).

Top of Page