Representatives Forms for San Diego
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FAQ
An Authorized Representative is someone you can name and give access to your Protected Health Information (PHI). An Authorized Representative can be family members, friends, or any other individual you choose.
You may give this form to your local county office in person or by mail, phone or electronically. Use this form to appoint an individual or organization as your Medi-Cal authorized representative. any time. You may give this form to your local county office in person or by mail, phone or electronically.
MC 382 (6/18) Use this form to appoint an individual or organization as your Medi-Cal authorized representative. Your authorized representative may act for you on all duties related to your Medi-Cal eligibility and enrollment. Or, you may also limit duties. You may cancel or change this appointment at any time.
Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.
MC 604 IPS (5/14) Page 2. Tell Us About Your Income And Expenses. Tell us about your income and expenses for you, your spouse and any of your children under 21 years of age who are living in the home, or are temporarily absent from the home for reasons such as attending school or work or is hospitalized.