Fillable 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 (Department of Health Care Services)

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State of California
Health and Human Services Agency
MC 381 (6/18)
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└ ┘
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Cancellation or Change to a Medi-Cal Authorized Representative Appointment
This notice is to tell you that the authorized representative appointment for
___________________________’s Medi-Cal case was cancelled or changed as of __________.
Here is more information about the changes to ___________________________’s appointment:
A
uthorized representative requested cancellation.
Applicant or beneficiary requested cancellation
Applicant or beneficiary asked for these changes to the authorized representative duties:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
If you have questions, please call the number listed at the top of this notice.
For County Use Only:
Notice Date:
Case Number:
Worker Name:
Worker ID Number:
Worker Phone Number:
Office Hours:
Office Address:
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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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