DHS 1121A “Agreement to Act as an Authorized Representative” Form Available For Use

HB1812 Relating to Health, was signed into law. This law clarifies that a health care surrogate appointed under the provisions of Hawaii Revised Statutes section 327E-5, may act as an authorized representative on behalf of an applicant or beneficiary during the Medicaid application process and for all other Medicaid related matters, provided all provisions for a Medicaid Authorized Representative are met. 

The Med-QUEST Division has developed a new form, the DHS 1121A, “Agreement to Act as an Authorized Representative” to allow an individual who has been appointed or given authority to represent an applicant or beneficiary, such as a Health Care Surrogate, Power of Attorney (POA), Office of Public Guardian (OPG), or other court appointed guardian, to be in compliance with the new law and Medicaid authorized representative requirements.

The form serves as evidence that the individual who has agreed to be an authorized representative will adhere to the regulations as required by Medicaid relating to confidentiality of information, conflict of interest and reassignment of provider claims.

Modified on October 15, 2018