DESIGNATE or REVOKE PRINT Applicant/Beneficiary First Name Middle Initial Last Name to act on my behalf in all medical PRINT Authorized Representative First Name Middle Initial Last Name or Organization assistance matters with the Department. Applicant/Beneficiary Signature Date Mailing Address Cit.
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How to fill out the HI DHS 1121 online
The HI DHS 1121 form, known as the Designation or Revocation of an Authorized Representative, is essential for managing Medicaid-related affairs in Hawaii. This guide provides a clear, step-by-step approach to filling out the form online, ensuring that you can confidently designate an authorized representative or revoke an existing designation.
Follow the steps to complete the HI DHS 1121 form online.
- Click ‘Get Form’ button to download the form and open it in your preferred editor.
- Print the full name of the Applicant or Beneficiary. You should also check the appropriate box to indicate whether you are designating or revoking authorization for the representative.
- Print the full name of the Authorized Representative or organization in the designated section.
- Fill in the mailing address for the Applicant or Beneficiary, including city, state, and zip code.
- The Applicant or Beneficiary must sign their name and provide the date of signing. If the signature is marked with an 'x,' ensure a witness is present to verify the mark.
- Complete the field indicating the date or event that dictates when the authorization stays valid. This step is crucial, as leaving it blank invalidates the authorization.
- The Authorized Representative must fill in their mailing address and telephone number, and then sign and date the form, affirming their understanding of the associated regulations.
- After filling out the form, submit the original and a copy to your assigned eligibility worker. It is advisable to retain a copy for your personal records.
Complete your HI DHS 1121 form online today to ensure proper representation in your Medicaid matters.
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