Forms

Enrollment

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

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) 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).