Fillable Appointment Of Representative printable pdf download

State of California -- Health and Human Services Agency

Department of Health Care Services

APPOINTMENT OF REPRESENTATIVE

SECTION I

TO BE COMPLETED BY APPLICANT

BENEFICIARY

Name

Case number (optional)

Date

I appoint this individual

_______________________________________ / _______________________________________

Name of individual

Name of organization

____________________________________________________________________________________________________

Complete address

Telephone number

as my authorized representative to accompany, assist, and represent me in my application for, or redetermination of, Medi-Cal

benefits.

THIS AUTHORIZATION ENABLES THE ABOVE NAMED INDIVIDUAL TO

submit requested verifications to the county welfare department;

●

accompany me to any required face-to-face interview(s);

●

obtain information from the county welfare department and from the State Department of Social Services, Disability

●

Evaluation Division, regarding the status of my application;

provide medical records and other information regarding my medical problems and limitations to the county welfare

●

department or the State Department of Social Services, Disability Evaluation Division;

accompany and assist me in the fair hearing process; and

●

receive one copy of a specific notice of action from the county welfare department, at the request of the

●

applicant/beneficiary.

I UNDERSTAND THAT I HAVE THE RESPONSIBILITY TO

complete and sign the Statement of Facts;

●

attend and participate in any required face-to-face interview(s);

●

sign MC 220 (Authorization for Release of Medical Information);

●

provide all requested verifications before my Medi-Cal eligibility can be determined; and

●

accept any consequences of the authorized representative’s actions as I would my own.

●

I UNDERSTAND THAT I HAVE THE RIGHT TO

choose anyone that I wish to be my authorized representative;

●

revoke this appointment at any time by notifying my Eligibility Worker; and

●

request a fair hearing at any time if I am not satisfied with an action taken by the county welfare department.

●

Applicant/Beneficiary’s signature

Date

➤

Address

SECTION II

TO BE COMPLETED BY THE AUTHORIZED REPRESENTATIVE NAMED

LAW FIRMS

ORGANIZATIONS

AND GROUPS

MAY REPRESENT THE APPLICANT

BENEFICIARY BUT AN INDIVIDUAL MUST BE DESIGNATED AS THE CONTACT PERSON TO ACT ON

THE APPLICANTS

BENEFICIARIES BEHALF

I HEREBY ACCEPT THE ABOVE APPOINTMENT AND UNDERSTAND THAT

the applicant/beneficiary may revoke this authorization at any time and appoint another individual(s) to act as his/her

●

authorized representative;

I have no other power to act on behalf of the applicant/recipient, except as stated above;

●

I may not act in lieu of the applicant/beneficiary; and

●

I may not transfer or reassign my appointment without a new Appointment of Representative form being completed by the

●

applicant/recipient.

I CERTIFY THAT

I have not been suspended or prohibited from practice before the Social Security Administration

●

I am not, as a current or former officer or employee of the United States, disqualified from acting as the applicant’s

●

representative; and

I am known to be of good character.

●

This authorization is recognized for one year from the date signed by the applicant unless revoked earlier as described in

Section 1 above.

Authorized representative’s signature

Employed by

Date

Telephone number

➤

COUNTY USE ONLY

____________________________________

_____________________________________

____________________________________________________________________

Date verbal request to revoke received

Date written request to revoke received

Request received from:

EW name: __________________________________________________________________________

Telephone number: _________________________

MC 306 (06/07)

Appointment Of Representative

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