Get Form 1721

Filling out Form 1721, which pertains to the revocation of appointment of a designated representative in consumer-directed services, requires careful attention to detail. This guide will walk you through each section to ensure that you complete the form accurately and efficiently.

Follow the steps to complete Form 1721 online:

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. In the first section, enter the individual's full name who is initiating the revocation. Ensure that the name is spelled correctly.
3. Provide the employer's name in the designated field. This should reflect the name of the person or entity revoking the designated representative.
4. In the section labeled 'Relationship of Employer to Individual Receiving Services,' select the appropriate relationship by marking the corresponding option. Choices include 'Self', 'Court-Appointed Guardian', 'Parent of a Minor', or 'Other Legally Authorized Representative (LAR)'.
5. In the statement section, you will fill in the employer's name again, affirming that they will fulfill all responsibilities without a designated representative. This demonstrates the intent to revoke previous authorization.
6. Specify the effective date of the revocation. Make sure the date is accurate and clear to avoid confusion.
7. Both the employer and a witness must print their names and sign where indicated. Each person must also provide the date of their signature to validate the form.
8. Once you have completed all sections and confirmed accuracy, you can save changes, download, print, or share the filled-out form as needed.

Take action today by completing Form 1721 online and ensure your revocation is processed smoothly.