Form 1721, Revocation of Appointment of Designated Representative
Effective Date: 1/2007
English PDF: 1721.pdf
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.
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.
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.
The employer must keep this form for five years after termination of the agreement, or until all outstanding litigation, claims and audits are resolved.
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).