Health human services agency 2026

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The document is a form from the State of California's Health and Human Services Agency that allows individuals to appoint an authorized representative for Medi-Cal eligibility and enrollment matters. It outlines the responsibilities of both the applicant and the authorized representative, including duties such as completing applications, reporting changes, and handling appeals. The form also provides options for limiting the representative's duties and ensures confidentiality of information.

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Click ‘Get Form’ to open the Appointment of Authorized Representative in the editor.
In Part A, provide your personal information including your name, phone number, case number (optional), and mailing address. Ensure all details are accurate for effective communication.
Move to Part B and enter the details of your authorized representative. This includes their name, phone number, mailing address, and email address.
In Part C, specify the duties you wish to assign to your authorized representative. You can choose from a list of duties or limit them as needed.
Indicate whether you want your authorized representative to receive copies of Medi-Cal notices by selecting one of the options provided.
Finally, read through Part D carefully. Sign and date the form to confirm your appointment of the authorized representative.

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2018	4.9 Satisfied (24 Votes)

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mc 382

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