Forms

Enrollment

Family PACT Provider Application (DHCS 4468) Form

 

Client

Effective May 3, 2021, the Health Access Programs (HAP) client enrollment system for the Family Planning, Access, Care and Treatment (Family PACT) Program was updated. As a result, the Family PACT Client Eligibility Certification (CEC) and Retroactive Eligibility Certification (REC) forms were also updated.

The new CEC (English and Spanish) and the REC (English and Spanish) forms are available for downloading from this page, and also available on the Medi-Cal Provider Forms web page. Previous versions of the Family PACT eligibility forms should not be used on or after May 3, 2021.

Client Eligibility Certification (CEC) (DHCS 4461) form – English | Client Eligibility Certification (CEC) (DHCS 4461) form – Spanish

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

Providers

Superbill (Excel) 6/1/21

Superbill (PDF) ADA Compliant format 6/1/21

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).