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California health care services 2026
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- Click ‘Get Form’ to open it in the editor.
- In Section I, enter your name and case number (optional). Specify the individual you are appointing as your representative, including their name and organization.
- Provide the complete address and telephone number of your authorized representative. This person will assist you in your Medi-Cal application process.
- 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.
- Sign and date the form at the bottom of Section I to confirm your appointment of the representative.
- 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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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2007 | 4.8 Satisfied (100 Votes) |
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