TX HHS Form 1721. Revocation of Appointment of Designated Representative

The TX HHS Form 1721, Revocation of Appointment of Designated Representative, is a crucial document for individuals or organizations seeking to terminate the use of a designated representative (DR) in consumer-directed services. This form helps solve the problem of revoking the authority of a DR, ensuring that the employer takes on full responsibility for fulfilling all obligations without relying on a third party.

This form is typically used by employers who need to revoke the appointment of a DR due to changes in circumstances or to assume full control over their responsibilities. The document requires specific information from the employer, including their name, relationship to the individual receiving services, and signature. Additionally, the form specifies that the revocation of use of a DR is effective on a particular date.

Key features of this form include the requirement for the employer's printed name, signature, and date. The form also emphasizes the importance of fulfilling all employer responsibilities without the use of a designated representative. By using this form, employers can ensure a smooth transition and avoid any potential issues or conflicts that may arise from revoking the appointment of a DR.

• This form is used to revoke the appointment of a designated representative (DR) in consumer-directed services.
• The employer must provide their printed name, signature, and date on the form.
• The form specifies that the revocation of use of a DR is effective on a particular date.