Mc306 2025

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An Authorized Representative is an individual with legal authority to bind the government entity (e.g., the Chief Executive Officer of the government entity).
You may request Medi-Cal to pay retroactively for the three months prior to the month in which you apply.
Your authorized representative may act for you on all duties related to your Medi-Cal eligibility and enrollment. Or, you may also limit duties. You may cancel or change this appointment at any time. You may give this form to your local county office in person or by mail, phone or electronically.
Where do I send my MC 382 form? Mail the form to address Access, PO Box 85027, San Diego, CA 92186. Please include the case number on the form when doing so. The form will be scanned into the system and a representative will contact you.
Authorized Representative Standard Agreement for Organizations Form (MC 383) The purpose of the MC 383 is for an individual acting on behalf of an organization that was named as an AR to sign an agreement under penalty of perjury to adhere to federal and state regulations.
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MC 382 (6/18) Use this form to appoint an individual or organization as your Medi-Cal authorized representative. Your authorized representative may act for you on all duties related to your Medi-Cal eligibility and enrollment. Or, you may also limit duties. You may cancel or change this appointment at any time.

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