Health human services agency 2025

1. Click ‘Get Form’ to open it in the editor.
2. In Part A, provide your personal information including your name, phone number, case number (if applicable), and mailing address. Ensure all details are accurate for effective communication.
3. Move to Part B and enter the details of your authorized representative. This includes their name, phone number, mailing address, and email address. Double-check for any typos.
4. In Part C, specify the duties you wish to assign to your authorized representative. You can choose from the provided examples or limit their duties as needed.
5. Indicate whether you want your authorized representative to receive copies of Medi-Cal notices by selecting the appropriate option.
6. Finally, read through Part D carefully before signing. Your signature confirms the appointment of your authorized representative and acknowledges your rights and responsibilities.

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