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

  • APPOINTMENT OF REPRESENTATIVE

  • SECTION I. TO BE COMPLETED BY APPLICANT/BENEFICIARY

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  • 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.

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