APPOINTMENT OF REPRESENTATIVE

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

Month Day Year
Date
Name

Marnice Smith
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.
Address

Street Address

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City State / Province

Postal / Zip Code
Date

Month Day Year
Date
Applicant/Beneficiary’s signature

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State of California -- Health and Human Services Agency Department of Health Care Services

APPOINTMENT OF REPRESENTATIVE

THIS AUTHORIZATION ENABLES THE ABOVE NAMED INDIVIDUAL TO:

I UNDERSTAND THAT I HAVE THE RESPONSIBILITY TO:

I UNDERSTAND THAT I HAVE THE RIGHT TO: