Family PACT Provider Application (DHCS 4468) Form
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.
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
The Superbill is a billing template (sample) and not a required Family PACT form.
Superbill (Excel) 12/15/22
Superbill (PDF) 12/15/22 (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).