TX HHS Form 1721. Revocation of Appointment of Designated Representative

The Texas Health and Human Services (HHS) Form 1721, Revocation of Appointment of Designated Representative, is used to notify the agency that an employer will no longer utilize a designated representative (DR) for consumer-directed services. This form is essential for employers who wish to fulfill their responsibilities without the assistance of a DR.

This document serves as official notice to HHS and relevant parties that the employer has chosen to revoke the appointment of their designated representative, effective on the specified date. The form requires the employer's printed name, signature, and date, as well as the witness's printed name, signature, and date.

The Revocation of Appointment of Designated Representative Form 1721 is an important tool for employers in Texas to manage their responsibilities and obligations regarding consumer-directed services. By understanding the purpose and usage of this form, individuals can ensure compliance with HHS regulations and maintain accurate records of their employer's representative status.