Form MC381 "Cancellation or Change to a Medi-Cal Authorized Representative Appointment" - California

What Is Form MC381?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Available in Arabic;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MC381 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form MC381 "Cancellation or Change to a Medi-Cal Authorized Representative Appointment" - California

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State of California
Health and Human Services Agency
For County Use Only:
Notice Date:
Case Number:
Worker Name:
Worker ID Number:
Worker Phone Number:
Office Hours:
Office Address:
Cancellation or Change to a Medi-Cal Authorized Representative Appointment
This notice is to tell you that the authorized representative appointment for
___________________________’s Medi-Cal case was cancelled or changed as of __________.
Here is more information about the changes to ___________________________’s appointment:
 Authorized representative requested cancellation.
 Applicant or beneficiary requested cancellation
 Applicant or beneficiary asked for these changes to the authorized representative duties:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
If you have questions, please call the number listed at the top of this notice.
MC 381 (6/18)
State of California
Health and Human Services Agency
For County Use Only:
Notice Date:
Case Number:
Worker Name:
Worker ID Number:
Worker Phone Number:
Office Hours:
Office Address:
Cancellation or Change to a Medi-Cal Authorized Representative Appointment
This notice is to tell you that the authorized representative appointment for
___________________________’s Medi-Cal case was cancelled or changed as of __________.
Here is more information about the changes to ___________________________’s appointment:
 Authorized representative requested cancellation.
 Applicant or beneficiary requested cancellation
 Applicant or beneficiary asked for these changes to the authorized representative duties:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
If you have questions, please call the number listed at the top of this notice.
MC 381 (6/18)