Resource Type: Forms
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.