Designation of Personal Healthcare Representative Form

IMPORTANT: It’s almost time to renew your Medi-Cal coverage. You will get a letter in the mail that tells you if your Medi-Cal was renewed automatically by the county or if your county needs more information. If you receive a renewal packet or a notice asking for more information, please visit KeepMediCalCoverage.org for the next steps.

Search
separator
separator
X
Close
EnglishEnglish
EnglishEnglishArabicArabicChinese (Simplified)Chinese (Simplified)Chinese (Traditional)Chinese (Traditional)DutchDutchFilipinoFilipinoFrenchFrenchGermanGermanHindiHindiItalianItalianJapaneseJapaneseKoreanKoreanPersianPersianPortuguesePortugueseRussianRussianSlovakSlovakSpanishSpanishVietnameseVietnamese

Prospect Medical Systems / For Members / Member Form

Designate Personal Representative

If a patient choses to designate a personal representative to act on behalf of the patient in making healthcare-related decisions and have unlimited access to the patient's information, please download and complete this form.

If the patient is a minor, a parent or legal guardian must sign.

If the patient is unable to sign for any other reason, a legal representative must sign the designation and submit documentation to verify the authority to sign.

Questions? Call Us at
(800) 708-3230

Email Us!