Form DHS 1121 Designation or Revocation of an Authorized Representative - Hawaii

Form DHS1121 is a Hawaii Department of Human Services form also known as the "Designation Or Revocation Of An Authorized Representative". The latest edition of the form was released in October 1, 2018 and is available for digital filing.

Download an up-to-date Form DHS1121 in PDF-format down below or look it up on the Hawaii Department of Human Services Forms website.

ADVERTISEMENT
STATE OF HAWAII
Med-QUEST Division
Department of Human Services
P.O Box 700190
Kapolei HI, 96709-0190
DESIGNATION OR REVOCATION OF AN AUTHORIZED REPRESENTATIVE
 DESIGNATE or  REVOKE
I,
_____________________________________________________________
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
City
State
Zip Code
If signed with “x” by the Applicant/Beneficiary:
______________________________________________
_________________________________________ __________
PRINT Witness First Name Middle Initial Last Name
Signature of Witness
Date
Note: Witness cannot be your designated Authorized Representative.
This authorization is valid from the DATE OR *EVENT this form is signed by the Applicant/Beneficiary:
Date _______ / ______ / _______ OR Event: ____________________________________________
Month
Day
Year
As the Authorized Representative, by signing below:
1. I understand that as a condition of serving as an Authorized Representative, I must affirm that
I will adhere to the regulations in 42 CFR 431 Subpart F (relating to safeguarding information
on applicants and beneficiaries), 42 CFR 435.923 (relating to authorized representatives), 45
CFR 155.260 (relating to confidentiality of information) and 42 CFR 447.10 (relating to the
prohibition against reassignment of provider claims as appropriate for the facility or an
organization action on the facility’s behalf).
2. I agree that I shall be legally bound by the federal and state authorities related to authorized
representatives, including but not limited to maintaining the confidentiality of any information
provided to me by the Department or its designee in compliance with all state and federal
confidentiality laws and conflicts of interest laws.
3. I understand that my role as an authorized representative for the purposes of Medicaid shall
terminate when:
a. Revoked by an applicant/beneficiary with decisional capacity;
b. Upon appointment or availability of a Guardian or Power of Attorney designated to make
health care decisions for the applicant/beneficiary: or
c. Upon the applicant/beneficiary’s death.
4. I also understand that my role as an authorized representative is valid until:
a. The applicant/beneficiary withdraws the authorization by notifying the Department that I
am no longer authorized to act on the applicant’s or beneficiary’s behalf;
b. There is a change in the legal document of authority to act on the applicant’s or
beneficiary’s behalf; or
c. I inform the Department that I am no longer acting as the applicant/beneficiary’s
authorized representative.
__________________________________________________________________________________________________
Signature of Authorized Representative (required)
Telephone
Date
__________________________________________________________________________________________________
Mailing Address
City
State
Zip Code
* EVENT-The Privacy Rule requires that an Authorization contain either an expiration date or an expiration event that
relates to the individual or the purpose of the disclosure. For example, an Authorization may expire "one year from the
date the Authorization is signed" or "upon termination of enrollment in the health plan."
FOR OFFICIAL USE ONLY
UNIT:
WKR:
CID:
Date:
DHS 1121 (Rev. 10/18)
Page 1 of 2
STATE OF HAWAII
Med-QUEST Division
Department of Human Services
P.O Box 700190
Kapolei HI, 96709-0190
DESIGNATION OR REVOCATION OF AN AUTHORIZED REPRESENTATIVE
 DESIGNATE or  REVOKE
I,
_____________________________________________________________
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
City
State
Zip Code
If signed with “x” by the Applicant/Beneficiary:
______________________________________________
_________________________________________ __________
PRINT Witness First Name Middle Initial Last Name
Signature of Witness
Date
Note: Witness cannot be your designated Authorized Representative.
This authorization is valid from the DATE OR *EVENT this form is signed by the Applicant/Beneficiary:
Date _______ / ______ / _______ OR Event: ____________________________________________
Month
Day
Year
As the Authorized Representative, by signing below:
1. I understand that as a condition of serving as an Authorized Representative, I must affirm that
I will adhere to the regulations in 42 CFR 431 Subpart F (relating to safeguarding information
on applicants and beneficiaries), 42 CFR 435.923 (relating to authorized representatives), 45
CFR 155.260 (relating to confidentiality of information) and 42 CFR 447.10 (relating to the
prohibition against reassignment of provider claims as appropriate for the facility or an
organization action on the facility’s behalf).
2. I agree that I shall be legally bound by the federal and state authorities related to authorized
representatives, including but not limited to maintaining the confidentiality of any information
provided to me by the Department or its designee in compliance with all state and federal
confidentiality laws and conflicts of interest laws.
3. I understand that my role as an authorized representative for the purposes of Medicaid shall
terminate when:
a. Revoked by an applicant/beneficiary with decisional capacity;
b. Upon appointment or availability of a Guardian or Power of Attorney designated to make
health care decisions for the applicant/beneficiary: or
c. Upon the applicant/beneficiary’s death.
4. I also understand that my role as an authorized representative is valid until:
a. The applicant/beneficiary withdraws the authorization by notifying the Department that I
am no longer authorized to act on the applicant’s or beneficiary’s behalf;
b. There is a change in the legal document of authority to act on the applicant’s or
beneficiary’s behalf; or
c. I inform the Department that I am no longer acting as the applicant/beneficiary’s
authorized representative.
__________________________________________________________________________________________________
Signature of Authorized Representative (required)
Telephone
Date
__________________________________________________________________________________________________
Mailing Address
City
State
Zip Code
* EVENT-The Privacy Rule requires that an Authorization contain either an expiration date or an expiration event that
relates to the individual or the purpose of the disclosure. For example, an Authorization may expire "one year from the
date the Authorization is signed" or "upon termination of enrollment in the health plan."
FOR OFFICIAL USE ONLY
UNIT:
WKR:
CID:
Date:
DHS 1121 (Rev. 10/18)
Page 1 of 2
FORM PURPOSE
The DHS 1121 “Designation or Revocation of an Authorized Representative” form is used as Hawaii
Med-QUEST Division’s documentation of an applicant’s or beneficiary’s signed designation or
revocation of the Authorized Representative or Organization to act on their behalf in all Medicaid related
matters and on-going communications with the Department.
FORM INSTRUCTIONS
An individual chosen to be an Authorized Representative is required to complete and sign the DHS
1121 as it is evidence that the Authorized Representative has attested to maintain the confidentiality
of any information regarding the applicant or beneficiary as required by Medicaid regulations and
understands regulations in relation to conflicts of interest.
If the applicant or beneficiary is signing with an “x” as their signature, they acknowledge and accept
the information contained in the DHS 1121. A witness of the applicant/beneficiary mark is required to
ensure that the applicant/beneficiary made the mark and was not forged. The witness cannot be the
designated Authorized Representative.
1. PRINT the Applicant/Beneficiary full name and check appropriate box to designate or revoke
authorization of representative.
2. PRINT the Authorized Representative full name.
3. PRINT the Applicant/Beneficiary address.
4. The Applicant/Beneficiary shall sign their name and date.
5. The Applicant/Beneficiary must complete the Date or Event that the authorization is valid
until. If the Date or Event is left blank the authorization is not valid.
6. The Designate Authorized Representative must review, complete their mailing address and
telephone number, and sign and date in the area designated to affirm that they understand
the regulations relating to being designated as the Applicant/Beneficiary Authorized
Representative.
7. Upon completion of this form, return the original and a copy of the document authorizing you
to be a representative to your assigned eligibility worker. You may also contact Customer
Service at 524-3370 or for your neighbor islands 1-800-316-8005, (TTY/TDD 711) for additional
information. You may keep a copy of this form for your records.
DHS 1121 (Rev. 10/18)
Page 2 of 2

Download Form DHS 1121 Designation or Revocation of an Authorized Representative - Hawaii

761 times
Rate
4.6(4.6 / 5) 53 votes
ADVERTISEMENT
Page of 2