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You may give this form to your local county office in person or by mail, phone or electronically. Do you want your authorized representative to get a copy of Medi-Cal notices or other mail we send to you? The authorized representative may cancel this appointment at any time.
An authorized representative is a non-household member who can apply for benefits, complete work registration forms, complete required reporting or use the Electronic Benefits Card to purchase the households food. [7 U.S.C. 2020(e)(7); 7 C.F.R. 273.2(n)(1); MPP 63-402.61; ACL 19-55.]
MC 219 (11/15) ENG2. To verify immigration status with the Department of Homeland Security (DHS), if required. Information shared with DHS cannot be used for immigration enforcement unless you are committing fraud.
Phone numbers: Medi-Cal Managed Care: 1-800-430-4263 (TTY 1-800-430-7077)
An Authorized Representative is someone you can name and give access to your Protected Health Information (PHI). An Authorized Representative can be family members, friends, or any other individual you choose.
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People also ask

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.
An Authorized Representative can be family members, friends, or any other individual you choose. For example, you may want your spouse or adult child to help with billing questions, booking appointments, or to be aware of your health status.
Medi-Cal applicants and participants can designate individuals, such as their family members or friends, or organizations as an authorized representative (AR) for help communicating with Medi-Cal about enrollment and eligibility.

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