State of California Health and Human Services Agency Appointment of Authorized RepresentativeUse this form to appoint an individual or organization as your MediCal authorized representative. Your.
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How to fill out the CA MC 382 online
The CA MC 382 form is used to appoint an individual or organization as your authorized representative for Medi-Cal. This guide will provide clear, step-by-step instructions on how to complete the form online, ensuring that you can effectively communicate your preferences regarding your Medi-Cal representation.
Follow the steps to fill out the CA MC 382 form online
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In Part A, provide your details as the applicant or beneficiary. Fill in your name, phone number, mailing address, and optional case number.
- In Part B, enter information about the authorized representative. Include their name, phone number, mailing address, and email address.
- In Part C, specify the duties you want to assign to your authorized representative. You can choose to allow them to handle all listed responsibilities or limit their duties.
- Indicate whether you want your authorized representative to receive copies of Medi-Cal notices and other mail by checking the appropriate box.
- In Part D, review and sign the acknowledgment. Your signature and date are required to confirm your appointment of the authorized representative, as well as the optional signature of the representative themselves.
- After completing the form, you can save your changes, download the document, print it, or share it as needed.
Start filling out the CA MC 382 form online today to ensure your Medi-Cal representation is appointed according to your wishes.
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What is AOR form?
Appointment of Authorized Representative (Purpose: To grant permission for another individual or company to act on your behalf in filing a Grievance or Appeal).
What is MC 382?
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.
Where do I send my MC 382?
Where do I send my MC 382 form? Mail the form to address Access, PO Box 85027, San Diego, CA 92186. Please include the case number on the form when doing so.
What is an authorized representative?
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.
Who is an authorized signer for Medi-Cal?
Currently, the only person(s) authorized to sign Medi-Cal enrollment documents on behalf of provider groups is the individual(s) who is the sole proprietor, partner, corporate officer or an official representative of a governmental entity or non-profit organization who has the authority to legally bind the group.
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