Resource Type: Forms
Family PACT Site Certifier for Multiple Locations Declaration (DHCS 4475)
Client Educational Materials Order
Retroactive Eligibility Certification (REC) (DHCS 4001)
Client Eligibility Certification (CEC) (DHCS 4461)
test
Family PACT Practitioner Agreement (DHCS 4470)
*The DHCS 4470 is not required to be completed by Primary Care Clinics, Affiliate Primary Care Clinics, RHCs, IHCs, and government providers.