Enrollment

Family PACT Program Provider Agreement (DHCS 4469) Form October 2025

Family PACT Program Practitioner Participation Agreement (DHCS 4470)* Form September 2024

*The DHCS 4470 is not required to be completed by Primary Care Clinics, Affiliate Primary Care Clinics, RHCs, IHCs, and government providers.

Family PACT Program Site Certifier for Multiple Sites Declaration (DHCS 4475) Form October 2025

Client

Client Eligibility Certification (CEC) (DHCS 4461) form – English  May 2025

Client Eligibility Certification (CEC) (DHCS 4461) form – Spanish July 2025

Client Eligibility Certification (CEC) (DHCS 4461) form – Chinese May 2022

Client Eligibility Certification (CEC) (DHCS 4461) form – Korean May 2022

Client Eligibility Certification (CEC) (DHCS 4461) form – Vietnamese May 2022

Retroactive Eligibility Certification (REC) (DHCS 4001) form – English March 2021

Retroactive Eligibility Certification (REC) (DHCS 4001) form – Spanish March 2021

Providers

The Superbill is a billing template (sample) and not a required Family PACT form.

Superbill (Excel) December 2022

Superbill (PDF) December 2022

Client Education Materials Order Form

Sterilization Consent (PM 330) Forms in English and Spanish can be downloaded from the Forms webpage of the Medi-Cal website or can be ordered by calling the Telephone Service Center at 1-800-541-5555. Providers must supply their NPI number when ordering the form(s).