Family PACT


    Forms

    Warning Effective immediately, any Female and Male Medical Exam templates previously posted on the Family PACT website are no longer to be used for medical record documentation. These templates are not considered adequate for medical record documentation for services billed for reimbursement under the Family PACT Program.

    Female Medical Exam form            Male Medical Exam form 

    Medical Record Documentation

    The Family PACT Standards require medical documentation to support services billed for reimbursement. Medical record documentation shall reflect the clinical rationale for providing, ordering or deferring services to clients according to Family PACT Standards, including, but not limited to, client assessment, diagnosis, treatment and follow-up.

    Medical record documentation shall reflect the scope of education and counseling services provided to clients according to Family PACT Standards, including, but not limited to, individual client assessment, topics discussed and name and title of counselor.

    All medical record entries must be legible and the clinician must be clearly identifiable. In accordance with W&I Code, section 24005(p), each provider of health care services rendered to any program beneficiary shall keep and maintain records of each service rendered, the beneficiary to whom the service was rendered, the date and any additional information that the department may by regulation require.

    Family PACT Program, Policies, Procedures and Billing Instructions Manual Sections:

  • Provider Responsibilities (prov res)
  • Program Standards:
      •   (F) Clinical and Preventive Services 
      •   (G) Education and Counseling

 

ICD-10 Superbill  Effective 8/28/18 (Excel)

ICD-10 ADA Compliant Superbill  Effective 8/28/18 (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 Eligibility Certification Forms

 Client Eligibility Certification (CEC) DHCS 4461(11/16 PDF)

 Client Eligibility Certification (CEC) DHCS 4461SP (11/16 PDF)

 

Retroactive Eligibility Certification Forms

Retroactive Eligibility Certification (REC) DHCS 4001 (11/16 PDF)

Retroactive Eligibility Certification (REC) DHCS 4001SP (11/16 PDF)                  

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