MC382 Appointment of Authorized Representative

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What Is Form MC382?

The MC382 document is also known as the Appointment of Authorized Representative. You can fill in the blank if you need to name some organization or specific individual as your own Medi-Cal representative.

This person, based on the rights you’ve trusted them with according to the authorized representative form Medi Cal will make decisions on your behalf when you will not be able to do this. You will not have to deal with Medi-Cal enrollment and eligibility. However, you still can put the limit to the duties of this person or organization and include it in this appointment of authorized representative form.

The document must be sent to the county office of your area. You can do it in person, by phone, or send it online. It was created by the State of California Health and Human Services Agency. If you change your mind you can also cancel form MC 382 by contacting the county office you’ve previously sent the agreement.

MC382 Appointment of Authorized Representative Screenshot

What I need the form MC382 for?

  • The form allows you to choose an authorized representative Medi-Cal will accept as the one who acts on your behalf. This person will perform all the duties that are somehow related to you and your enrollment;
  • The Medi Cal authorized representative form is required by an organization or individual who you want to trust the right to act on your behalf. Without this document the person will not be able to be your representative;
  • This document must be sent to the local county so they can make it official, and trust the person you choose as your representative. The person who acts on your behalf without the form does not have rights to do so.

How to Fill Out Form MC382?

You will find an authorized representative Medi Cal here on PDFLiner. The form is not complicated to understand. You have to provide information about yourself and the representative you trust. It is 3 pages long and contains numerous explanations. The form is free of charge. You can download it on your own device, fill it online via PDFLiner, send it via email, online, or regular mail. Here is what you need to include there:

  1. Complete section A with the information about you, phone number, case number if you have, and address that can be used to send mail;
  2. Include the information about the representative you’ve chosen in section B with the name, phone, email, and mailing address;
  3. Circle the duties you want to trust the person and tell their limits;
  4. Put the ticks in the appropriate boxes near the questions on representative rights;
  5. Read the details on the assignments that can be fulfilled by representative based on Medi-Cal official regulations;
  6. Sign the document and put the date if you are agreeing with the terms and conditions in the document. If not you can also go back to the limitations and put some more;
  7. Give the document to the representative to sign it and put the current date.

Organizations that work with form MC382

  • State of California Health and Human Services Agency;
  • Local county.
Fillable online MC382 Appointment of Authorized Representative
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(4.9 / 5) 106 votes
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