Forms

Family PACT Superbill

Family PACT Superbill Updated 4-7-2014 (Excel)

Sterilization Consent Form Ordering

Copies of the sterilization Consent Form (PM 330) can be downloaded (in English and Spanish) from the Forms page of the Medi-Cal website or ordered by calling the Telephone Service Center (TSC) at 1-800-541-5555.

Providers must supply their NPI number when ordering the form(s). The following information also may be requested:

  • Date
  • Name of document (sterilization Consent Form, PM 330)
  • Name of provider/facility (registered provider name associated with the NPI)
  • Complete shipping address: Street, city, state, ZIP code (P.O. Box not accepted)
  • Quantity of forms requested
  • Contact person and telephone number

Client Enrollment Certification Forms

Client Enrollment Certification (CEC) DHCS 4661 (Updated 3/14) (PDF) (English)

Client Enrollment Certification form (Updated 1-12) (PDF) (Spanish) 

Retroactive Eligibility Certification Forms

Retroactive Eligibility Certification (REC) (DHCS 4001) (Updated 3/14) (PDF) (English)

Retroactive Eligibility Certification form (Updated 1-12) (PDF) (Spanish)

Medical History Forms

Female History Form – English (4-08) PDF | Word

Female History Form – Spanish (4-08) PDF | Word

Male History Form – English (4-08) PDF | Word

Male History Form – Spanish (4-08) PDF | Word

 

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This document was updated last at 08-Apr-2014 04:15 PM