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This Authorized Representative form is enclosed for this purpose. If you want to authorize someone to represent you at the hearing please complete this form and either bring it to your hearing or have your representative bring it to the hearing on your behalf. You should notify your representative of the time and place of your hearing. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AUTHORIZED REPRESENTATIVE State of California Department of Social Services P. O. Box 944243 M. S* 9-17-37 Sacramento California 94244-2430 I of Name Address City State and Zip have requested Organization City and Zip to act on my behalf in my appeal regarding my application for and/or receipt of Assistance Program I hereby authorize your department to release any or all information relating to this request to this person/organization* Signed DPA 19 12/10 PAGE 1 OF 2 IF YOU STILL WANT YOUR HEARING it is required that you attend the hearing or have someone appe....

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• To choose an authorized representative to represent the applicant/recipient at. a state administrative hearing, complete a separate form, DPA 19 (Authorized. Representative). The person authorized on the completed and submitted DPA 19 form can represent the applicant/recipient at a state administrative hearing.

An authorized representative's primary role is to represent an individual or company in different official transactions. They have the authority to communicate, liaise, negotiate, and make decisions ing to goals and project requirements.

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.

(Failure to complete this form in its entirety will invalidate this authorization) An Authorized Representative is a person you authorize to act on your behalf, in pursuing a claim or an appeal of a denied claim.

An authorized representative is an individual or organization that you select to represent your interests in the hearing process. This may be a friend, relative, co-worker, neighbor, a lawyer (in private practice), Legal Services or an advocacy group that represents claimants in public assistance hearings.

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.

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.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232