____________________________________________________________________________________________________
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)
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