Follow the steps to successfully complete the HI DHS 1121 Instructions.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the full name of the applicant or beneficiary clearly in the designated field. Select the appropriate checkbox to indicate whether you are designating or revoking an Authorized Representative.
3. Provide the full name of the Authorized Representative in the specified area.
4. Fill in the address of the applicant or beneficiary accurately to ensure proper communication.
5. The applicant or beneficiary must sign their name and date the form. If signing with an 'X', acknowledgment of the information on the form is required.
6. Indicate the date or event for which the authorization will remain valid. If this field is blank, the authorization will be considered invalid.
7. The Authorized Representative needs to review, complete their mailing address and telephone number, then sign and date in the specified area to affirm their understanding of the regulations.
8. Once the form is completed, the Authorized Representative must return the original and a copy to their assigned eligibility worker for processing.
9. Finally, users have the option to save changes, download, print, or share the form for their records.

Start filling out your HI DHS 1121 Instructions online today to ensure your Medicaid representation is properly documented.