To fill out Form MC 382, download the one-page PDF from the Department of Health Care Services, enter your information in Part A, your representative’s information in Part B, choose the scope of duties and mail handling in Part C, sign Part D, and send the completed form to the county social services office handling your Medi-Cal case.1California Department of Health Care Services. Medi-Cal Eligibility Division MC 300 Forms The form itself is short. The parts that trip people up are limiting the representative’s authority, deciding what mail they get, and the extra rules that kick in when the representative is an organization.
Where to Get the Form
The fillable PDF is on the DHCS Medi-Cal Eligibility Division forms page, listed as “MC 382 (06/18) – Appointment of Authorized Representative Form.”1California Department of Health Care Services. Medi-Cal Eligibility Division MC 300 Forms Fill in the fields on-screen, then print the completed form to sign. Paper copies are also available at any county social services office.
Part A: Your Information
Enter your name, mailing address, and phone number. Part A also has a field for your Medi-Cal case number, but it is marked optional, so first-time applicants who do not have a case number yet can leave it blank.2California Department of Health Care Services. MC 382 Appointment of Authorized Representative Form The form does not ask for a Social Security Number or date of birth.
Part B: Representative Information
Write the name of the person or organization you are appointing, along with their mailing address, email, and phone number.2California Department of Health Care Services. MC 382 Appointment of Authorized Representative Form If you are appointing a legal aid group, community organization, or other entity, put the organization’s name here. Organizations have additional requirements covered further down.
Part C: Duties and Mail
By default, your representative can handle every task related to your Medi-Cal eligibility and enrollment. The form lists six examples of what that covers:2California Department of Health Care Services. MC 382 Appointment of Authorized Representative Form
- Completing and signing the application
- Completing and signing redetermination (renewal) forms
- Providing information the county requests
- Reporting changes in your circumstances
- Choosing a health plan
- Helping with fair hearings and appeals
If you want to hold some tasks back, Part C has a write-in space where you describe the limits. You might, for example, let the representative handle renewals and report changes while keeping health plan selection and hearings to yourself.
Part C then asks what mail the representative should receive. You pick one of three options: no notices, all notices and mail, or only specific types of notices that you write in.2California Department of Health Care Services. MC 382 Appointment of Authorized Representative Form If the whole point of the appointment is to have someone else manage your case, “all notices” is the practical pick. If you only want help with a single task, limiting the mail keeps other correspondence private.
Part D: Signatures
Your signature as the applicant or beneficiary is required. By signing, you confirm that the appointment is voluntary, that your own rights and responsibilities under Medi-Cal are unchanged, and that you remain responsible for responding to requests for information.2California Department of Health Care Services. MC 382 Appointment of Authorized Representative Form The authorization takes effect on the date you sign.
The representative’s signature line is marked optional. When the representative signs, they agree to follow state and federal rules for authorized representatives, including privacy and confidentiality requirements, and to keep information they receive from Medi-Cal confidential.2California Department of Health Care Services. MC 382 Appointment of Authorized Representative Form Having them sign makes the expectations clear on both sides.
Accepted Signature Methods
California law requires Medi-Cal agencies to accept electronic signatures (including telephonically recorded ones) and handwritten signatures sent by fax or other electronic transmission.3California Legislative Information. California Welfare and Institutions Code 14014.5 You can print the form, sign it by hand, and scan or fax the signed copy. Some counties also accept designations made through the BenefitsCal online portal or by phone.4Santa Clara County Social Services Agency. Persons Who May Represent a Client Counties cannot insist on an original wet signature only.
How to Submit the Form
Send the completed MC 382 to the county social services office handling your Medi-Cal case. You can mail it, fax it, or hand-deliver it to a county intake worker. DHCS notes that fill-and-print PDFs should be “completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing.”1California Department of Health Care Services. Medi-Cal Eligibility Division MC 300 Forms Keep a copy of the signed form. It is your proof of the appointment if the original is lost in processing.
Once the county processes the form, your case file is updated with the representative’s contact information. If you elected to have notices sent to the representative, future correspondence about benefit changes, renewals, or hearings will go to them, either in addition to you or in your place, depending on the option you picked in Part C.
When a Power of Attorney Replaces the Form
Under both federal and California law, legal authority granted by a court order or power of attorney counts as a written designation of authorized representation, so you do not always need a separate MC 382.5eCFR. 42 CFR 435.923 – Authorized Representatives Whether you can skip the form depends on the type of power of attorney:
- A Durable Power of Attorney for Health Care holder who can make health care decisions for someone unable to act on their own behalf does not need to file an MC 382 separately. Ask the county to place the power of attorney document on file instead.
- A Durable Power of Attorney for Property Management holder still needs an MC 382 or other written proof of authorization on file with the county.4Santa Clara County Social Services Agency. Persons Who May Represent a Client
Extra Rules When the Representative Is an Organization
Naming an organization in Part B triggers additional requirements. Only people who represent that organization and who have a signed MC 383, the Authorized Representative Standard Agreement, on file with the county can actually perform duties under the appointment.2California Department of Health Care Services. MC 382 Appointment of Authorized Representative Form The organization must also give you a written disclosure of any conflicts of interest that could result from acting as your representative.
The same conflict-of-interest disclosure applies to an individual representative who works for or contracts with a health care provider or facility. The written disclosure has to happen before the representative starts acting on your behalf.3California Legislative Information. California Welfare and Institutions Code 14014.5
Changing or Ending the Appointment
An MC 382 authorization stays in effect until you cancel it, modify it, or appoint a new representative, or until the representative contacts the county to withdraw.3California Legislative Information. California Welfare and Institutions Code 14014.5 There is no built-in expiration date. Either side can end the arrangement at any time by notifying the county handling the Medi-Cal case.2California Department of Health Care Services. MC 382 Appointment of Authorized Representative Form
To swap in a different representative, submit a new MC 382 naming the replacement. The new appointment replaces the old one. If you only want to adjust the scope of duties or the mail settings, contact your county office and ask whether a new form is needed or whether the change can be made by phone, email, or through the online portal.