Provider Enrollment Forms
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What forms do I need to complete?
You will need to complete:
- The Application to Participate in the Family PACT Program (CDPH 4468)
- Family PACT Program Provider Agreement (CDPH 4469)
- Family PACT Program Practitioner Agreement (CDPH 4470) (This form is not required to be completed by nonprofit community clinics, FQHCs, RHCs, THCs and government providers.)
- Family PACT Program Disclosure Statement (CDPH 4471)
To complete these forms, you may need:
- A current copy of your driver's license
- Proof of Federal Tax ID number or social security number
- Current copy of fictitious name permit, if applicable
- Individual pracitioner's Medi-Cal provider number
- Current copy of practitioner's medical license
- Articles of Incorporation, if applicable
Follow all the instructions carefully and submit all the forms and
the Certificate of Attendance (from your Provider Orientation session)
to:
California Department of Public Health
Office of Family Planning
Family PACT Provider Enrollment
1615 Capitol Avenue, MS-8306
PO Box 997420
Sacramento, CA 95899-7420
Click here for the Provider Enrollment Checklist (PDF). (Updated 5-08)
If you have any questions:
- Call the Provider Resource Line at 1-877-FAMPACT or
1-916-650-0285
- Email us at fampact@cdph.ca.gov
This document was updated last at Thursday, June 05, 2008