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State of California Health and Human Services Agency (Department of Health Care Services)

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State of California
Health and Human Services Agency
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For County Use Only:
Notice Date:
Case Number:
Worker Name:
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Worker ID Number:
Worker Phone Number:
Office Hours:
Office Address:
Notice of Authorized Representative Appointment
This notice is for applicants, beneficiaries and recently appointed authorized representatives.
This notice applies to .
You got this notice because:
• You appointed a Medi-Cal authorized representative, or
• You were appointed as a Medi-Cal authorized representative.
The role of an authorized representative
An applicant or beneficiary appoints an individual or organization as an authorized representative
to help with all or some duties related to their Medi-Cal eligibility and enrollment. They also
choose if copies of notices and other mail may be sent to the authorized representative. The
authorized representative helps with duties until:
• Cancellation by either the applicant or beneficiary, or the authorized representative; or
• 90 days after denial or discontinuance (unless cancelled by either party).
For the applicant or beneficiary
An “Appointment of Authorized Representative” form (MC 382) came with this notice. The form
lists the duties you granted your authorized representative. Part C of the form lists the copies of
notices and other mail you asked us to send to your authorized representative, if any.
The county’s contact information is at the top of this letter. Contact us if you want to:
• Change your authorized representative’s duties.
• Change the notices or other mail that are sent to the authorized representative
• Cancel the appointment of your authorized representative.
MC 380 (6/18) 1
State of California
Health and Human Services Agency
For the authorized representative
By accepting the appointment as an authorized representative, you agree:
• To obey all state and federal laws for authorized representatives. These include, but are
not limited to, laws about confidentiality of information, prohibitions against reassignment of
provider claims and conflicts of interest.
• If you are an employee or contractor for a health care provider, you must give the applicant
or beneficiary a written disclosure before you may act on their behalf. The disclosure must
describe:
° Your employment or contract with the health care provider or facility.
° Any potential conflicts of interest.
• You may cancel your status as an authorized representative at any time by telling the
county office.
Organizations Only: Each person acting on behalf of the organization must file a signed
Authorized Representative Standard Agreement form (MC 383) with the county office. To get a
copy of this form, contact the county office.
For more information about Medi-Cal rights and responsibilities, read the MC 219 “Important
Information for Persons Requesting Medi-Cal” that came with this notice.
If you do not agree with the responsibilities in this notice or do not want to be an authorized
representative, contact the county office.
MC 380 (6/18) 2
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State of California Health and Human Services Agency (Department of Health Care Services)

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Completed 30 July 2020

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