Form DMHC20-160 "Authorized Assistant Form" - California

What Is Form DMHC20-160?

This is a legal form that was released by the California Department of Managed Health Care - 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 January 1, 2020;
  • The latest edition provided by the California Department of Managed Health Care;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DMHC20-160 by clicking the link below or browse more documents and templates provided by the California Department of Managed Health Care.

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Download Form DMHC20-160 "Authorized Assistant Form" - California

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State of California - Health and Human Services Agency
Department of Managed Health Care
AUTHORIZED ASSISTANT FORM - English
DMHC 20-160
New: 04/06
Rev: 01/20
AUTHORIZED ASSISTANT FORM
If you want to give another person permission to assist you with your Independent Medical
Review (IMR) or complaint, complete Parts A and B below.
If you are a parent or legal guardian filing this IMR or complaint for a child under the age of 18,
you do not need to complete this form.
If you are filing this IMR or complaint for a patient who cannot complete this form because the
patient is either incompetent or incapacitated, and you have legal authority to act for this
patient, please complete Part B only. Also attach a copy of the power of attorney for health
care decisions or other documents that say you can make decisions for the patient.
PART A: COMPLETED BY PATIENT
I allow the person named below in Part B to assist me in my IMR or complaint filed with the
Department of Managed Health Care (Department). I allow the Department and IMR staff to share
information about my medical condition(s) and care with the person named below. This information
may include mental health treatment, HIV treatment or testing, alcohol or drug treatment, or other
health care information.
I understand that only information related to my IMR or complaint will be shared.
My approval of this assistance is voluntary and I have the right to end it. If I want to end it, I must
do so in writing.
Patient Name (Print)
Patient Signature
Date
PART B: COMPLETED BY PERSON ASSISTING PATIENT
Name of Person Assisting (Print)
Address
City
State
Zip
Relationship to Patient
Primary Phone #
Secondary Phone #
Email Address
 My power of attorney for health care decisions or other legal document is attached.
State of California - Health and Human Services Agency
Department of Managed Health Care
AUTHORIZED ASSISTANT FORM - English
DMHC 20-160
New: 04/06
Rev: 01/20
AUTHORIZED ASSISTANT FORM
If you want to give another person permission to assist you with your Independent Medical
Review (IMR) or complaint, complete Parts A and B below.
If you are a parent or legal guardian filing this IMR or complaint for a child under the age of 18,
you do not need to complete this form.
If you are filing this IMR or complaint for a patient who cannot complete this form because the
patient is either incompetent or incapacitated, and you have legal authority to act for this
patient, please complete Part B only. Also attach a copy of the power of attorney for health
care decisions or other documents that say you can make decisions for the patient.
PART A: COMPLETED BY PATIENT
I allow the person named below in Part B to assist me in my IMR or complaint filed with the
Department of Managed Health Care (Department). I allow the Department and IMR staff to share
information about my medical condition(s) and care with the person named below. This information
may include mental health treatment, HIV treatment or testing, alcohol or drug treatment, or other
health care information.
I understand that only information related to my IMR or complaint will be shared.
My approval of this assistance is voluntary and I have the right to end it. If I want to end it, I must
do so in writing.
Patient Name (Print)
Patient Signature
Date
PART B: COMPLETED BY PERSON ASSISTING PATIENT
Name of Person Assisting (Print)
Address
City
State
Zip
Relationship to Patient
Primary Phone #
Secondary Phone #
Email Address
 My power of attorney for health care decisions or other legal document is attached.