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Get and Sign N of the Health Access Programs Family Pact Program Client Eligibility Certification Cec Form 2014

Get and Sign N of the Health Access Programs Family Pact Program Client Eligibility Certification Cec Form 2014

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Eligible for Family PACT Program services. • Providers must keep this original form in your medical record. • Code areas are for Provider use only. (See PPBI, Client Eligibility Certification Form Completion Section for code determinations.) Do you currently receive Medi-Cal benefits or services? Yes No Do you have a Medi-Cal Benefits Identification Card (BIC)? Yes No Do you have health care insurance for family planning services? (Private insurance, Health Maintenance Organization...
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