State of California—Health and Human Services Agency
California Department of Public Health
APPLICATION TO PARTICIPATE IN THE FAMILY
PACT (PLANNING, ACCESS, CARE, AND TREATMENT) PROGRAM
(Section 24005, Welfare and Institutions Code)
IMPORTANT:
Must be a current Medi-Cal provider.
Read all attached materials before completing.
Type or print clearly in ink.
Signature of individual provider or individual is required (see page 4).
Return completed form to:
FOR STATE USE ONLY
California Department of Public Health
Office of Family Planning
Family PACT Provider Enrollment
1615 Capitol Avenue, MS 8400
P.O. Box 997420
Sacramento, CA 95899-7420
(916) 650-0414
Date received: _________________
Date approved: _________________
Date returned:__________________
Enrollment Action Requested:
New enrollment
Additional site address
Current National Provider Identifier (NPI):
Family PACT Provider Type:
Sole proprietor
Group provider
Government entity
Licensed Community/Free Clinic
Federally Qualified Health Center (FQHC); Rural Health Center (RHC); Indian Health Center (IHC)
1.a. Legal name of applicant (must be same name as used for current Medi-Cal provider number)
1.b. Contact person for this application
1.c. Contact person’s telephone number
2.a. Primary service site telephone number
2.b. FAX number
(
(
)
(
1.d. Contact person’s fax number
)
(
)
2.c. E-mail address
)
3.
Primary service site
4.
Primary service site address (number, street)
City
County
State
Nine-digit ZIP code
5.
Pay to address (number, street)
City
County
State
Nine-digit ZIP code
6.
Mailing address (number, street)
City
County
State
Nine-digit ZIP code
7.a. Fictitious Business Name Statement
number (attach copy), if applicable
7.b.
Effective date
8.
Date of birth
9.
Gender
Male
10.
Provider type (see Attachment A,
Title 22 CCR, Section 51051)
10.a. Board-certified specialty
12.
Federal Employer Identification Number (A copy of IRS Form 941, Form 8109–C,
Form SS-4 [Confirmation Notification], or Form 2363 must be submitted with the
application)
Female
11.a. License to Provide Health Services 11.b. Expiration date
effective date (attach copy)
13. Social security number (If Sole Proprietor not using a Tax Identification number, you
must disclose this number and attach a copy of the ITIN verification, if applicable.)
_____ _____ _____ — _____ _____ — _____ _____ _____ _____
Name of Sole Proprietor (last, first, middle)
____ ____ — ____ ____ ____ ____ ____ ____ ____
14.
NPI
CDPH 4468 (10/11)
15. Driver’s license number or state-issued identification number (attach legible copy)
Page 1 of 7
16. List below all service sites, other than the one listed in question 4, at which Family PACT services will be provided. Identify the Medi-Cal
NPI for each site. List all NPIs, service sites, and addresses that are applicable under this application. Please attach a separate
sheet of paper for any additional sites and NPIs not listed below.
Service site name
Address (number, street)
NPI
City
State
ZIP code
Telephone number
(
Service site name
Address (number, street)
NPI
City
State
ZIP code
Telephone number
(
Service site name
Address (number, street)
City
State
Service site name
ZIP code
Telephone number
City
State
Service site name
ZIP code
Telephone number
City
State
Service site name
ZIP code
Telephone number
City
State
Service site name
ZIP code
Telephone number
City
State
Service site name
ZIP code
Telephone number
City
State
Service site name
ZIP code
Telephone number
)
NPI
City
State
ZIP code
Telephone number
(
CDPH 4468 (10/11)
)
NPI
(
Address (number, street)
)
NPI
(
Address (number, street)
)
NPI
(
Address (number, street)
)
NPI
(
Address (number, street)
)
NPI
(
Address (number, street)
)
NPI
(
Address (number, street)
)
)
Page 2 of 7
17. Practitioners
Please identify all practitioners (medical doctors, certified nurse midwives, nurse practitioners, physician assistants) who will be providing
clinical family planning services under the Family PACT program. You may attach a list with the following information if it is easier than
using the format provided below.
SERVICE SITE/
PRACTITIONER’S NAME
PROVIDER TYPE
(e.g., M.D., CNM, NP, PA)
CALIFORNIA LICENSE
NUMBER
INDIVIDUAL
NPI
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
CDPH 4468 (10/11)
Page 3 of 7
Orientation and Training Session
Applicants are required to attend a Provider Orientation session mandated by the legislation implementing Family
PACT before they can participate in the Family PACT program. The original copy of the certificate of attendance
must be attached to this Family PACT Application.
I have received, and have on file, a completed Practitioner Agreement from each practitioner identified in the
Application. I am duly authorized to commit all service sites, provider numbers, and practitioners specified in this
application. I understand that providers who do not provide services consistent with the “Family PACT Standards”
for Administrative Practices and Clinical Reproductive Health Services may be permanently disenrolled as a
provider from the Family PACT program. I understand that incorrect or inaccurate information may affect my
eligibility to participate in the Family PACT program and receive Medi-Cal reimbursement and that I must report
changes to the above information to the California Department of Health Care Services, Medi-Cal Provider
Enrollment Branch (DHCS-PEB). This includes any change of location or practitioner which must be reported to
DHCS-PEB within 35 days of the change. Failure to comply may result in permanent disenrollment from the Family
PACT program.
Provider agrees: (a) that compliance with the provisions of this application is a condition precedent to payment to
the provider. The parties agree that this application is a legal and binding document and is fully enforceable in a
court of competent jurisdiction. The individual provider signing this application or the individual signing the
application on behalf of a group understands it and is authorized to execute it; (b) to certify clients for eligibility for
the Family PACT program, and recertify on an annual basis, according to certification instructions issued by the
California Department of Public Health (CDPH); (c) to cooperate with and participate in the evaluation effort of the
Family PACT program determined by CDPH; (d) to make administrative files and billing and medical records
pertaining to the Family PACT program available at reasonable times for inspection, auditing, monitoring, or
evaluation by state auditors/quality improvement staff for a period of four years from the end of the fiscal year in
which the client encounter took place.
I declare under penalty of perjury under the laws of the State of California that the foregoing Application
(CDPH 4468), Provider Agreement (CDPH 4469), Practitioner Agreement (CDPH 4470), and Disclosure Statement
(CDPH 4471) information is true, accurate, and complete to the best of my knowledge and belief.
18.
Type or print name of individual provider signing the application or individual
signing the application on behalf of a group
19.
Signature (original blue ink only)
CDPH 4468 (10/11)
Title of individual signing the application
Date
Page 4 of 7
INSTRUCTIONS FOR COMPLETION OF APPLICATION TO PARTICIPATE IN THE FAMILY PACT PROGRAM
1. Legal name means the name under which the applicant or provider is applying for enrollment or continued enrollment.
Contact person who is familiar with the application and can be contacted for questions. Contact’s telephone number and
fax number.
2. Primary service site telephone means the primary business telephone number used at the business location. A beeper
number, answering service, pager, facsimile machine, cellular phone, or answering machine is not acceptable. Also
include fax number and e-mail address, if available.
3. Primary service site means, if the provider has multiple sites, the site considered the main or headquarters site.
4. Primary service site address means the actual business location including the street name and number, room or suite
number or letter, city, county, state, and nine-digit ZIP code where Family PACT services are determined. A post office
box or commercial box is not acceptable.
5. Pay to address means the address to which the applicant wishes to receive payment. The Pay to Address should include,
as applicable, the post office box number, street number and name, room or suite number or letter, city, state, and
nine-digit ZIP code.
6. Mailing address is where the applicant or provider wishes to receive general Family PACT correspondence. Provide, as
applicable, the post office box number, street number and name, room or suite number or letter, city, state, and nine-digit
ZIP code.
7. If the name in number 2 is a Fictitious Business Name, provide the Fictitious Business Name Statement number. Attach a
clearly legible recorded-stamped copy of the Fictitious Business Name Statement with the application. If nonapplicable,
write “N/A.” Provide the effective date of the Fictitious Business Name Statement or Fictitious Name Permit.
8. List the date of birth of the applicant if an individual owner.
9. List the gender of the applicant if an individual owner.
10.
Indicate the provider type (see Attachment A list from Title 22, California Code of Regulations, Section 51051).
11.
If individual provider or licensed community clinic, provide the license/certificate number, or other approval to provide
health care, of the applicant or provider. Attach a clear legible copy of the license, certification, or approval. List the
effective date and expiration date of the license/certificate number, or other approval listed in number 11b. If a
governmental agency, write “exempt.”
12.
List the Federal Employer Identification Number issued by the Internal Revenue Service (IRS) under the name of the
applicant or provider. Attach a clearly legible copy of the IRS Form 941, Form 8109-C, Form SS-4 (confirmation
notification), or Form 2363.
13.
If the business is a sole proprietorship not using an Employer Identification Number, provide the social security number of
the Sole Proprietor. List the Sole Proprietor’s name. Provide a clearly legible copy of the social security card.
14.
List National Provider Identifier (NPI).
15.
Provide the driver’s license or state-issued identification number and state of issuance of the applicant or provider. Attach
a clearly legible copy with the application.
16.
List all additional service sites at which Family PACT services will be provided.
17.
List all practitioners and the service site where they will be providing Family PACT clinical family planning services.
18.
Name and title of individual provider signing the application or individual signing on behalf of a group means the first,
middle, and last name of individual who is applying to the Department for enrollment or continued enrollment as a provider
in the Family PACT program (typed or printed).
19.
An original signature, in blue ink, of the individual listed in number 18 is required. Also provide the title of the person
signing the application. Include the city, state, and date where and when the application was signed.
20.
Complete Attachment B, Identification Card Request Form, and include with mailed application. Failure to complete and
mail this form with the application will severely delay receipt of HAP cards.
!
Remember to enclose a copy of the following, if applicable:
•
•
•
•
Driver’s license or identification card
Social security card
Tax identification number verification
License, certificate, or other approval
CDPH 4468 (10/11)
•
•
Fictitious Business Name Statement
Identification Card Request Form (Attachment
B)
Page 5 of 7
Attachment A
Title 22, California Code of Regulations
§ 51051. Provider.
(a) "Provider" means any individual, partnership, provider group association, corporation, institution, or entity, and the
officers, director employees, or agents thereof, that provides services, goods, supplies, merchandise, directly or indirectly, to a
Medi-Cal beneficiary, that meet the Standards for Participation specified in Article 3 (commencing with Section 51200), and that
has been enrolled in the Medi-Cal program.
(b) Providers include, but are not limited to:
Acupuncturists
Assistive Device and Sick Room Supply Dealers
Audiologist
Blood Banks
Child Health and Disability Prevention Providers
Chiropractors
Christian Science Facilities
Christian Science Practitioners
Clinical Laboratories or Laboratories
Comprehensive Perinatal Providers
Dental School Clinics
Dentists
Dispensing Opticians
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Providers
EPSDT Supplemental Services Providers
Fabricating Optical Laboratory
Hearing Aid Dispensers
Home Health Agencies Hospices
Hospital Outpatient Departments
Hospitals
Incontinence Medical Supply Dealers
Intermediate Care Facilities
Intermediate Care Facilities for the Developmentally Disabled
Local Educational Agency Providers
Nurse Anesthetists
Nurse Midwives
Nurse Practitioners
Nurse Facilities
Occupational Therapists
Ocularists Optometrists
Orthotists
Organized Outpatient Clinics
Outpatient Heroin Detoxification Providers
Personal Care Service Providers
Pharmacies/Pharmacists
Physical Therapists
Physicians
Podiatrists
Portable X-ray Services
Prosthetists
Providers of Medical Transportation
Psychologists Rehabilitation
Centers Renal Dialysis Centers and Community Hemodialysis Units
Respiratory Care Practitioners
Rural Health Clinics
Short-Doyle Medi-Cal Providers
Skilled Nursing Facilities
Speech Therapists
Targeted Case Management Providers
Barclays CA, pages 403 and 404. Register 99, No.40; 10-1-99. CDPH 4468 Application Attachment.
CDPH 4468 (10/11)
Page 6 of 7
Attachment B
FAMILY PACT PROGRAM
HEALTH ACCESS PROGRAMS (HAP)
IDENTIFICATION CARD REQUEST FORM
Under the Family PACT (Planning, Access, Care and Treatment) Program, client eligibility will be determined by the medical
provider based upon the information provided by the client under self-certification. The provider will issue a Health Access
Program (HAP) identification card to the client. The client will use this card for access to other medical providers as well as
pharmacies and laboratories.
Individual sites listed on the Application and Agreement must order their own cards after the application has been approved.
Sites are not allowed to share cards.
This form is for a one-time only order for the first quantity of cards you estimate you will need. For a first time INITIAL
ORDER ONLY, please complete the information below and return this form with your Application and Agreement. HAP
enrollment cards will be issued in blocks of 100. For this initial order, please ONLY order the quantity expected to be used for a
six-month period.
Provider name
Street address
City
State
Zip
Provider telephone number
NPI
(
) __ __ __ __ __ __ __
Number of Health Access Program (HAP) identification cards needed:_________________
(Order a six-month supply in blocks of 100.)
Please allow eight weeks for receipt of your order.
FOR ALL FUTURE ORDERS, CALL THE HEALTH ACCESS
PROGRAMS HOTLINE AT 1-800- 541-5555
CDPH 4468 (10/11)
Page 7 of 7
