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Click ‘Get Form’ to open the Authorized Representative Form in the editor.
In Section 1, fill in your personal details as the Member or Minor’s parent/guardian. Include your Name, Member ID, Date of Birth, Telephone Number, and Address. Ensure you sign and date the form.
Proceed to Section 2. Here, check each box to acknowledge that you have read the conditions regarding the authorization of your representative. Specify an expiration date for this appointment if desired.
In Section 3, your appointed representative(s) must complete their information. They should provide their Name, Organization (if applicable), Relationship/Professional Status, Telephone Number, Address, and Signature along with the date.
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What information do I need? California Drivers License or Identification Card. Proof of California Residency. Immigration status. Birth Certificates, passports, naturalization certificates. Social Security and Medicare Card.
What paperwork do you need for Medi-Cal?
You will need to bring current proof of identification, income, expenses, assests, disability, and support.
What is the 3 month rule for Medi-Cal?
If you received a renewal form in the mail, you may submit your information by mail, phone, in person, or online to help avoid a gap in your Medi-Cal coverage.
What is the income limit for Medi-Cal in California?
Retroactive Medi-Cal covers unpaid medical expenses from the three months prior to the month you apply for Medi-Cal. If you have unpaid bills from the three previous months, enter that information during the application process. If you qualify for Medi-Cal, you will also be evaluated for retroactive coverage.
What documents do I need to apply for Medi-Cal Medicare?
To apply for Medicare, youll need: Your Social Security Card. Your original birth certificate. Proof of U.S citizenship or legal citizenship status documentation if you were not born in the U.S. A copy of your W-2 form.
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