Family PACT Provider Agreement (DHCS 4469) 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.
Superbill (Excel) 12/15/22
Superbill (PDF) 12/15/22 (ADA-compliant)
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).