Mc 383 2025

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  1. Click ‘Get Form’ to open the mc 383 in the editor.
  2. Begin by entering the organization name in the designated field. This identifies the entity acting as the authorized representative.
  3. Provide a contact phone number for the organization. This ensures that county representatives can reach out if needed.
  4. Fill in the organization’s mailing address, including street, city, state, and ZIP code. Accurate information is crucial for correspondence.
  5. Next, enter the applicant or beneficiary's name and their mailing address. If applicable, include their Medi-Cal case number for reference.
  6. Each authorized representative must sign and date below their respective names. Ensure all signatures are completed to validate the agreement.

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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.
This form allows you, as the IHSS applicant/recipient or their legal representative, to choose an Authorized Representative for the IHSS program. An Authorized Representative is responsible for acting on the behalf of the IHSS recipient for purposes of the IHSS program. This form is only for the IHSS program.
A Personal Representative has the authority to act as the member, and we must discuss the members PHI with them. For example, a Personal Representative can be a parent acting on behalf of a Medi-Cal dental member who is a minor.
Fiscal intermediary, as used in these regulations or in any other document pertaining to the Medi-Cal program and its administration, means any individual, partnership or association, corporation or institution contracting with the Department for the performance of fiscal services related to the program.
A Letter of Authorization authorizes payment for medical services received over 12 months before the current month. A Letter of Authorization is not required if the medical services were received within 12 months of the current month. Months still showing on the [INQM] screen in MEDS do not require an LOA.
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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.
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.

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