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