Dhs 1121-2025

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The document is a form from the Hawaii Department of Human Services, specifically the Med-QUEST Division, used for designating or revoking an Authorized Representative to act on behalf of an applicant or beneficiary in Medicaid-related matters. It outlines the responsibilities and legal obligations of the Authorized Representative, including maintaining confidentiality and adhering to federal and state regulations. The form requires signatures from both the applicant/beneficiary and the Authorized Representative, along with a witness if necessary.

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2018	4.1 Satisfied (60 Votes)

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