Forms Archives | California Family PACT

Client Educational Materials Order Form

Retroactive Eligibility Certification (REC) (DHCS 4001) form

Client Eligibility Certification (CEC) (DHCS 4461) form

Family PACT Practitioner Agreement (DHCS 4470) Form

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

Family PACT Provider Agreement (DHCS 4469) Form

Superbill