New Authorization Forms Now Available

Occasionally, an applicant wishes to let someone else speak with the Healthy Families Program (HFP) and/or Medi-Cal Programs about their application. However, due to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the HFP and Medi-Cal Programs cannot disclose information regarding program applications to anyone other than the person applying for coverage or their authorized representative. Therefore, in order for information to be released to someone other than the applicant, their spouse, or the other parent living in the home, the HFP and Medi-Cal Programs must first receive written permission. The applicant has several options for providing this written consent including completing the appropriate areas on the joint application, completing an Authorized Representative Form, or completing an Enrollment Entity (EE) Authorization Form.

Application
Question 52 of the Joint HFP/Medi-Cal for Children application provides a space for designating an Authorized Representative. By including a person's name on the Authorized Representative line in Question 52, the applicant agrees to allow that person to speak with the HFP and/or Medi-Cal Programs on the applicant's behalf. Authorized Representatives can also be designated using Health-e-App.

Authorized Representative Form
The Authorized Representative Form is a separate form from the application. Much like Question 52 of the application, this form allows the applicant to designate a particular individual as having permission to communicate with the HFP and/or Medi-Cal Programs on behalf of the applicant. This form must be signed and dated by the applicant and received by the HFP before information may be released. The Authorized Representative Form can be found on the HFP web site at: www.healthyfamilies.ca.gov/English/Publications/AuthorizedRepForm.pdf

Enrollment Entity Authorization Form
The new Enrollment Entity (EE) Authorization Form provides a means for an applicant to permit the HFP and Medi-Cal to speak with any employee or associate of a particular E E regarding their application. This form must be signed and dated by the applicant and received by the HFP before information may be released. The EE Authorization Form can be found on the HFP web site at: www.healthyfamilies.ca.gov/English/Publications/EEAuthorizationForm.pdf

The Authorized Representative Form and the EE Authorization Form are not interchangeable. In other words, the Authorized Representative Form is used to give permission only to a single specified person, whereas the EE Authorization Form is used to grant authority to any employee of the specified EE.

An authorized individual or EE may assist the applicant with their inquiry regarding the applicant's initial application, annual eligibility review, or first level appeal. Once the Program mails to the applicant its decision regarding the application, the authorized representative's permission ends.

For general questions regarding the use of these forms, please contact the EE/CAA Liaisons, Monday through Friday, 8:30 a.m. - 5:00 p.m., at 1-800-279-5012 or via email at ee-caaliaison@MAXIMUS.com.