Forms

Enrollment

Family PACT Provider Application (DHCS 4468) Form

Family PACT Provider Agreement (DHCS 4469) Form

Family PACT Practitioner Agreement (DHCS 4470) Form

Client

Client Eligibility Certification (CEC) (DHCS 4461) form – English  June 10, 2022

Client Eligibility Certification (CEC) (DHCS 4461) form – Spanish June 10, 2022

Retroactive Eligibility Certification (REC) (DHCS 4001) form – English | Retroactive Eligibility Certification (REC) (DHCS 4001) form – Spanish

Providers

Superbill (Excel) 09/08/22

Superbill (PDF) 09/08/22 (ADA-compliant)

Client Educational Materials Order Form

Sterilization Consent (PM 330) Forms in English and Spanish can be downloaded from the Forms web page 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).