Provider Enrollment

Provider Enrollment Process

Submit Application via Email

Complete form Provider Enrollment Application DHCS 4468 and submit it via secure email to This is the first form in the application process. You will receive the others after this one is approved.

Register in LMS

Register in the Learning Management System (LMS). This is where you will complete the required online trainings and learn the dates of the required in-person training.

Please contact us at or (916) 650-0414 with any questions.

Online Orientation

Complete the online Provider Orientation. After successful completion, you will be prompted to register for the in-person training.

In Person Orientation

Register for and attend an In-person Training. You will be prompted to register for this training after successful completion of the Online Orientation.

Provisional Enrollment Period

New Family PACT sites are provisionally enrolled for 6 months. During this Provisional Enrollment Period, all required trainings must be completed.


Family PACT Provider Enrollment Checklist

This is a checklist designed to help site certifiers, clinicians, and clinic staff familiarize themselves with the Family PACT program requirements for enrollment and for Site Certifiers/Providers to successfully navigate the enrollment process to become a Family PACT Provider.

Provider Enrollment Instructions


Application Process

Solo providers, group providers or primary care clinics, who currently have a National Provider Identifier (NPI), are enrolled in good standing with Medi-Cal, and have the family planning skills, competency and knowledge to provide comprehensive family planning are eligible to apply for enrollment into the Family Planning, Access, Care, and Treatment (Family PACT) Program. Providers must be able to provide the full range of services covered in the Program. Providers that are interested in enrolling into the Family PACT Program must apply for enrollment by completing and submitting an application packet. Please familiarize yourself with the requirements of the Family PACT Program and its provider enrollment requirements which can be found in the Family PACT Program’s Policies, Procedures and Billing Instructions Manual.

The application packet shall be completed by the provider applicant only. Effective November 1, 2018, applications received by third party consultants or enrollment brokers on behalf of the provider applicant will not be accepted. 

The current Family PACT application must be used when submitting an application to the Family PACT Program. Any packet submitted with an outdated application will be returned.

Please complete a Family PACT provider application packet and email or mail it to:


Department of Health Care Services
Office of Family Planning
P.O. Box 997413 MS 8400
Sacramento, California, 95899-7413

Each provider site must maintain legible copies of all initial and updated applications, as well as initial and updated practitioner agreements.

Physicians and Non-Physician Medical Practitioners (NMPs) employed by a Medi-Cal provider who is applying to enroll in the Family PACT Program and who will be delivering Family PACT services must be identified on the Provider Application (DHCS 4468), complete a Family PACT Program Provider Agreement (DHCS 4469)*, complete a Family PACT Program Practitioner Participation Agreement (DHCS 4470)*, and are required to complete the trainings identified on the Learning Management System.

*The DHCS 4469 and DHCS 4470 will be provided to applicants upon approval of the DHCS 4468 form.
            Please Note: The DHCS 4470 is not required to be completed by Primary Care Clinics, Affiliate Primary Care Clinics, FQHCs, RHCs, IHCs, and government providers.


Provisional Enrollment Period

If your application is approved, you will be provisionally enrolled. You will receive your Family PACT Welcome Letter. The initial HAP CARD order will be shipped separately. The HAP Card order shipment should be received in 8-10 business days.

New Family PACT service sites are provisionally certified for enrollment in Family PACT until an eligible representative completes the legislatively mandated Provider Orientation per Welfare and Institutions Code (W&I Code), Section (§) 24005(k). The Provider Orientation must be completed within six (6) months of the date of initial Family PACT enrollment for the provisional certification to be lifted. Failure to complete the orientation within six (6) months will result in disenrollment. Please visit our Learning Management System  for a complete list of required trainings and training locations.


What is the Provisional Enrollment Period (PEP)?

  • A Provisional Enrollment Period (PEP) is for newly enrolled Providers who have yet to complete all required trainings at the time their application is approved. Providers who are given a PEP can actively see clients and bill for services, but the site certifier must complete all required trainings within 6 months in order to remain enrolled in the Family PACT Program.
  • The 6 month Provisional Enrollment Period to complete all required trainings is typically 6 months from when the clinic submitted the application for enrollment in the Family PACT Program. If you are unsure of when the PEP expires, please reference your clinic’s Welcome Letter.
  • Providers who fail to complete the PEP within the allotted 6 months will be disenrolled from the Family PACT Program. Providers who have been disenrolled for this reason may re-apply for the Family PACT Program, but will not be granted a PEP, and must complete all required trainings before the application can be approved.


What trainings must be completed for the Provisional Enrollment Period to be lifted?

Trainings are determined based on your role in the clinic. See below:


Site Certifiers

  • In-Person Orientation (pre-requisite: All online trainings)

  • Online Orientation (Optional)

  • Fraud, Waste, and Abuse

  • Documenting FPACT Services
  • U.S. Medical Eligibility Criteria (2016)
  • U.S. Selected Practice Recommendations (2016)
  • Back Office Training


  • In-Person Orientation (Optional)

  • Online Orientation
  • Fraud, Waste, Abuse Training
  • Documenting Family PACT Services
  • U.S. Medical Eligibility Criteria (2016)
  • U.S. Selected Practice Recommendation (2016)
  • Back Office Training


  • In-Person Orientation (Optional)
  • Online Orientation
  • Fraud, Waste, Abuse Training
  • Documenting Family PACT Services
  • Back Office Training
  • Front Office Training


All OFP required trainings can be found on the Learning Management System.

Remember, providers are required to report any changes in practitioner personnel to DHCS OFP and PED within 35 days of the action taken and must also complete any required trainings outlined above.

When submitting changes to a Medi-Cal record (service address, NPI, TIN, legal or business name) providers are required to indicate these changes by completing an application packet to Family PACT Provider Enrollment. These changes do not require a provider to attend a provider orientation to certify the site.

Newly hired staff who fulfills the role of the Site Certifier and Clinician (non-Site Certifier) have 60 days from the date of hire to complete the required Provider Orientation and Trainings.

Please hold all training records onsite.

Health Access Program (HAP) Card Distribution

The Family PACT Program is discontinuing policy on annual distribution of HAP cards with annual limits.  All HAP card order requests will be forwarded to the Office of Family Planning for review.  All requests for additional HAP cards and the number of additional cards approved will be reviewed on a case-by-case basis. Initial HAP card orders for all new providers will remain at 200 sequential and revised to 50 blank HAP cards. The Telephone Service Center shall continue to process approved HAP card distributions.



Family PACT-enrolled providers must re-certify every three (3) years. Family PACT enrolled providers elected to re-certify will be notified by mail and must complete the steps outlined in Provider Enrollment for continued participation in the Family PACT Program.

Deactivation of Non-Participating Family PACT Providers

Effective January 1, 2019, the Department of Health Care Services will begin the process to deactivate providers from the Family PACT Program who have not submitted a claim for reimbursement from the program for one year.

Pursuant to Welfare and Institutions Code 24005 (i)(3), the department shall deactivate, immediately and without prior notice […] when a provider has not submitted a claim for reimbursement from the program for one year.

Deactivation from the Family PACT Program does not affect Medi-Cal enrollment. Deactivated providers will be notified by a letter sent to the address on file.