California health care services 2025

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, enter your name and case number (optional). Specify the individual you are appointing as your representative, including their name and organization.
3. Provide the complete address and telephone number of your authorized representative. This person will assist you in your Medi-Cal application process.
4. Review the responsibilities outlined for both you and your representative. Ensure you understand what is required from you, such as completing the Statement of Facts and attending interviews.
5. Sign and date the form at the bottom of Section I to confirm your appointment of the representative.
6. In Section II, have your appointed representative sign to accept their role. They must also provide their employment details and contact information.

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