Provider Enrollment

Who is eligible to enroll in Family PACT

Solo providers, group providers or primary care clinics are eligible to apply for enrollment in the Family PACT Program if they currently have a National Provider Identifier (NPI) and are enrolled in Medi-Cal in good standing.  Intermittent clinics and mobile clinics must apply for enrollment in the Family PACT Program using their organizational NPI and are enrolled in Medi-Cal in good standing.

The medical director, physician, nurse practitioner, or certified nurse midwife responsible for overseeing the family planning services to be rendered at the site to be enrolled is eligible to certify the site. Site certifiers shall sign a statement affirming responsibility.

A provider’s service location is certified for enrollment in the Family PACT Program when the provider meets all the Family PACT provider enrollment requirements. All Family PACT services shall be rendered at the enrolled service location(s) only

For detailed information on becoming a Family PACT provider, see the provider enrollment section (prov enroll) of the Policies Procedures and Billing Instructions (PPBI).

Application Forms

The Family PACT Program application package contains the following forms:

The information on the application forms must match the information on file in the Medi-Cal's Provider Master File database.

  • Each question on every page must be answered, unless otherwise noted.
  • Write "N/A" or draw a line through the field if a question is not applicable.
  • Do not leave any blank field.
  • Use of correction fluid or correction tape is not allowed.
  • The forms must be signed in any color other than black.

Additional Documentation

  • IRS-issued confirmation of Tax Identification Number (TIN) or Federal Employer Identification Number (FEIN)
  • State-issued photo identification of the person signing the forms
  • Solo provider’s Social Security card, unless using a FEIN

Submit Application Package To:

Submit all pages of DHCS 4468 and DHCS 4469, including the instruction pages, and retain a copy of the complete package at the service site. Mail the complete package to:

DHCS – Office of Family Planning
Family PACT Provider Enrollment
1615 Capitol Avenue, MS 8400
P.O. Box 997413
Sacramento, CA 95899-7413

Provider Orientation

New Family PACT provider applicants and/or new provider locations will be provisionally certified for enrollment in the Family PACT Program after the provider is enrolled in Medi-Cal and until an eligible representative attends a legislatively mandated provider orientation as determined by DHCS. A provider must attend an orientation within six (6) months of the date of initial Family PACT enrollment for the provisional certification to be lifted. If a provider and/or provider location’s provisional certification is not lifted within six (6) months of the date of initial Family PACT enrollment, that provider and/or provider location will be disenrolled from the Family PACT Program.

Certificates of Attendance are issued to site certifiers upon completion of a provider orientation. The original certificate is retained by DHCS. Certificates of Attendance are not transferable.

For details on upcoming Provider Orientations, visit the Provider Orientation page of this website.

Reporting a Change of Information

Providers are responsible for notifying the DHCS Provider Enrollment of Information Division within 35 days of any change in previously submitted information. When submitting changes to a Medi-Cal record (for example, changes to a service address, NPI, FEIN, legal name or business name), providers are required to submit a completed Application to Participate in the Family PACT Program (DHCS 4468) to Family PACT Provider Enrollment. These changes do not require a provider to attend a provider orientation to certify the service site.

If adding a new or additional service site, submitting a change of provider type, or a change of ownership, a provider must re-apply for enrollment in the Family PACT Program. For example, a new application to Family PACT is required when an individual provider changes its designation from a solo provider to a group provider.

If you have any questions:

Call Family PACT at (916) 650-0414
Email us at ProviderServices@dhcs.ca.gov  

 

 

This document was updated last at 03-Feb-2016 09:51 AM