Form DHCS4468 "Family Pact Provider Application" - California

What Is Form DHCS4468?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS4468 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS4468 "Family Pact Provider Application" - California

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State of California
Department of Health Care Services
Health and Human Services Agency
Dear Applicant:
To enroll as a Family, Planning, Access, Care and Treatment (Family PACT) provider, please complete the
enclosed Family PACT provider enrollment application package and return via secure email or mail to:
Email:
ProviderServices@dhcs.ca.gov
Mail: Department of Health Care Services
Office of Family Planning
P.O. Box 997413, MS 8400
Sacramento, 95899-7413
Please read all the instructions included in the application package carefully, complete each item
requested and submit pages 6 through 9 with all attachments. Incomplete application packages
will be deemed deficient and may result in a denial of the provider’s application.
Eligible Providers. Per California Welfare and Institutions Code (W&I Code), Section 24005(b) and (c),
eligible providers are licensed medical personnel with family planning skills, competency and knowledge,
who will provide the full range of services covered in the program, as long as these services are within
the provider’s scope of licensure and practice. Clinical providers electing to participate in the Family
PACT Program must be enrolled Medi-Cal providers in good standing.
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. An affiliate primary care clinic or APCC’s enrollment in the Family PACT Program is
dictated by W&I Code, Section 24005(t)(1) and (2). Intermittent clinics, as defined by Health and Safety
Code (H&S Code), Section 1206(h) and mobile clinics, as defined by H&S Code, Sections 1765, 120,
1765.150 and 1765.155, must apply for enrollment in the Family PACT Program using their organizational
NPI. The organizational NPI must be enrolled in Medi-Cal in good standing. The application packet shall
be completed by the provider applicant only. Applications received by third party consultants or
enrollment brokers will not be accepted.
Providers are required to submit their NPI with each application package.
Service Site. A provider’s service site is where services are rendered. The service site is certified for
enrollment in the Family PACT Program when the provider meets all the Family PACT provider
enrollment requirements set forth in the Family PACT Policies, Procedures and Billing Instructions (PPBI)
Manual. All information on the application must match the information on file with the Department of
Health Care Services, Provider Enrollment Division.
Non-Physician Medical Practitioners. Non-Physician Medical Practitioners (NMPs) employed by a
Medi-Cal provider who is applying to enroll in the Family PACT Program and who will be delivering Family
PACT services must be identified on the application.
Provisional Enrollment. New Family PACT provider applicants, new provider locations, and/or Family
PACT provider applicants recertifying their enrollment, will be provisionally certified for enrollment in the
Family PACT program once the provider is enrolled in the Family PACT Program, and until an eligible
representative completes a legislatively mandated Provider Orientation as determined by DHCS. The
Page 1 of 9
DHCS 4468 (12/18)
State of California
Department of Health Care Services
Health and Human Services Agency
Dear Applicant:
To enroll as a Family, Planning, Access, Care and Treatment (Family PACT) provider, please complete the
enclosed Family PACT provider enrollment application package and return via secure email or mail to:
Email:
ProviderServices@dhcs.ca.gov
Mail: Department of Health Care Services
Office of Family Planning
P.O. Box 997413, MS 8400
Sacramento, 95899-7413
Please read all the instructions included in the application package carefully, complete each item
requested and submit pages 6 through 9 with all attachments. Incomplete application packages
will be deemed deficient and may result in a denial of the provider’s application.
Eligible Providers. Per California Welfare and Institutions Code (W&I Code), Section 24005(b) and (c),
eligible providers are licensed medical personnel with family planning skills, competency and knowledge,
who will provide the full range of services covered in the program, as long as these services are within
the provider’s scope of licensure and practice. Clinical providers electing to participate in the Family
PACT Program must be enrolled Medi-Cal providers in good standing.
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. An affiliate primary care clinic or APCC’s enrollment in the Family PACT Program is
dictated by W&I Code, Section 24005(t)(1) and (2). Intermittent clinics, as defined by Health and Safety
Code (H&S Code), Section 1206(h) and mobile clinics, as defined by H&S Code, Sections 1765, 120,
1765.150 and 1765.155, must apply for enrollment in the Family PACT Program using their organizational
NPI. The organizational NPI must be enrolled in Medi-Cal in good standing. The application packet shall
be completed by the provider applicant only. Applications received by third party consultants or
enrollment brokers will not be accepted.
Providers are required to submit their NPI with each application package.
Service Site. A provider’s service site is where services are rendered. The service site is certified for
enrollment in the Family PACT Program when the provider meets all the Family PACT provider
enrollment requirements set forth in the Family PACT Policies, Procedures and Billing Instructions (PPBI)
Manual. All information on the application must match the information on file with the Department of
Health Care Services, Provider Enrollment Division.
Non-Physician Medical Practitioners. Non-Physician Medical Practitioners (NMPs) employed by a
Medi-Cal provider who is applying to enroll in the Family PACT Program and who will be delivering Family
PACT services must be identified on the application.
Provisional Enrollment. New Family PACT provider applicants, new provider locations, and/or Family
PACT provider applicants recertifying their enrollment, will be provisionally certified for enrollment in the
Family PACT program once the provider is enrolled in the Family PACT Program, and until an eligible
representative completes a legislatively mandated Provider Orientation as determined by DHCS. The
Page 1 of 9
DHCS 4468 (12/18)
State of California
Department of Health Care Services
Health and Human Services Agency
Provider Orientation must be completed within six (6) months of the date of initial Family PACT enrollment
for the provisional certification to be lifted. Failure to complete the Provider Orientation within six (6) months
will result in disenrollment from the Family PACT program.
Providers who are enrolled in Medi-Cal, in good standing, and have submitted a Family PACT application
may attend a Provider Orientation to certify a site for enrollment.
The medical director, Medical Doctor (MD), Certified Nurse Practitioner (CNP), or Certified Nurse Midwife
(CNM) responsible for overseeing the family planning services to be rendered at the site establishing
enrollment is eligible to certify the site. Site certifiers shall sign a statement of affirming responsibility.
Provider Orientation details and registration information are posted on the Family PACT website at
www.familypact.org.
Records Retention. To participate in the Family PACT Program, providers must maintain legible copies of
all initial and updated applications and initial and updated practitioner agreements at the provider site.
Reporting a Change of Information. Providers are required to report any change in previously
submitted information to DHCS Office of Family Planning (OFP) and DHCS Provider Enrollment
Division (PED) within 35 days of the action taken. 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 packet to Family PACT Provider Enrollment.
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.
Provider Disenrollment. Providers may terminate their participation in the Family PACT Program at any
time by providing written notification of voluntary termination to Family PACT Provider Enrollment. The
letter should be on provider or clinic letterhead and must include the NPI, the service site address,
effective date of disenrollment and the provider-owner's signature.
Providers are subject to disenrollment for failure to adhere to program policies and administrative
practices. Failure to notify DHCS Provider Enrollment Division and the Office of Family Planning/Family
PACT Program of any changes to previously submitted information (for example, a change of service
location) may result in disenrollment from the Family PACT Program. On-site visits and attempts at
corrective action may be made prior to disenrollment at DHCS’ discretion. Disenrollment from the Family
PACT Program by DHCS is not subject to administrative appeal.
DHCS may restrict the participation of a provider in Medi-Cal through suspension or determine that a
provider is ineligible to participate in the Medi-Cal program. If a provider is suspended from the Medi-Cal
program, enrollment in the Family PACT Program is terminated effective the date of the Medi-Cal
suspension and Family PACT services are no longer reimbursable.
If you have any additional enrollment questions, please contact the Family PACT Program at
(916) 650-0414 or by email at ProviderServices@dhcs.ca.gov.
Family PACT Program
Enclosure(s)
Page 2 of 9
DHCS 4468 (12/18)
State of California
Department of Health Care Services
Health and Human Services Agency
INSTRUCTIONS FOR COMPLETING OF THE
FAMILY PACT PROVIDER APPLICATION (DHCS 4468)
DO NOT USE staples on this form or on any attachments.
DO NOT USE correction tape, white out, or highlighter pen on this form. If you must make corrections,
please line through, date, and initial in ink.
DO NOT LEAVE any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you.
Omission of any information or documentation on this form or failure to sign any of the required
documents may result in a denial of the provider's application.
Submit one application packet for each service site.
The information on the application forms must match the information on file with the DHCSPED.
Original signatures are required. Please use blue ink only.
This form is part of an application for enrollment or continued enrollment as a provider in the
Family PACT Program. Applicants may be subject to an on-site inspection and to unannounced
visits prior to enrollment or approval for continued enrollment in the program. In addition to this
form and requested documentation, a Family PACT Provider Agreement (DHCS 4469) and Family
PACT Practitioner Participation Agreement (DHCS 4470) must also be completed for enrollment
or continued enrollment. The DHCS 4470 is not required to be completed by an APCC, nonprofit
community clinic or PCC, Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or
Indian Health Services (IHS). Additional information can be found on the Family PACT website
(www.familypact.org) by clicking the “Providers” tab, followed by “Provider Enrollment”.
Important:
Read all instructions and gather the following documents to submit with the application. Please
remember to include a legible copy of the following with your application packet.
 IRS issued Taxpayer Identification Number (TIN)
 License to provide health services
 Fictitious Business Name Statement, if applicable
 Driver’s license or state issued identification card of individual signing the application
 Additional documentation requested by DHCS.
National Provider Identifier (NPI)—enter the NPI of the primary service site.
Date – enter the date you are completing the application.
Enrollment Action Requested—check all actions that apply.
"New Provider”—check if the provider is not currently enrolled in the Family PACT Program as
a provider with an active provider number.
“Recertification”— Do not check this box unless you have received notification from the Department to
apply for continued enrollment in the Family PACT Program.
“Change of service site address”—check if the provider is currently enrolled in the Family PACT
Program and is requesting to relocate to a new business address and vacate the old location.
DHCS 4468 (12/18)
Page 3 of 9
State of California
Department of Health Care Services
Health and Human Services Agency
“New Taxpayer ID number”—check if a new Taxpayer Identification Number (TIN) was issued by the
IRS. Indicate new TIN number and attach a legible copy of the IRS form 941, Form 8109-c, Letter 147-C,
Form 2363, Form SS-4 or Exempt Form 1023.
“Change of ownership”—check if there is a change of ownership as defined in CCR, Title 22, Section
51000.6. Indicate the effective date in the space provided.
“Previous Family PACT Provider”-Were you previously enrolled into the Family PACT Program? If yes,
provide your NPI.
“Medi-Cal Enrollment Status”—check if the site is currently enrolled in the Medi-Cal program. Indicate the
application enrollment status, as applicable.
“Type of entity”—check the box which applies to your business structure. Your corporate status will be
verified using the corporate number and state in which incorporated. If a partnership, you must attach a
legible copy of the partnership agreement. If you check “other”, list the type of legal entity.
1. “Service Site Legal Name” the service site name listed with the Internal Revenue Service (IRS).
2. “Service Site Business Name” the service site business name (i.e. fictitious name if applicable).
3. “Service Site Telephone Number” is the primary service site telephone number used at the service
location. A cell phone, answering service, facsimile machine, biller or billing service, or answering
machine shall not be used as the primary service site telephone number.
4. “Service Site Email Address” is the primary service site email used at the service location.
5. “Service Site Fax Number” is the primary service site fax used at the primary service location.
6. “Fictitious Business Name”— check if the business name is fictitious. If this is a fictitious business
name, provide the Fictitious Business Name Statement/Permit number and effective date. Attach a
legible copy of the recorded/stamped Fictitious Business Name Statement/Permit to the application. If
non-applicable, write “N/A”.
7. “Service Site Address” is the address, including the street name and number, room or suite number or
letter, city, county, state, and nine-digit ZIP code where services are rendered. A post office or
commercial box is not acceptable. The address must match the address submitted to Medi-Cal for
enrollment.
8. “Pay-to-Address” is the address at which the provider 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. The address must match the address submitted to
Medi-Cal for enrollment.
9. “Mailing Address” is the address at which the provider wishes to receive general DHCS
correspondence. The mailing 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. The address
must match the address submitted to Medi-Cal for enrollment.
10. “License Number” enter the license/certificate number, or other approval to provide health care
services at the service site. If you are a licensed clinic, attach a legible copy of the license or certificate,
issued by California Department of Public Health. If you are a physician, attach a legible copy of the
license or certificate issues by the California Department of Consumers Affairs/Medical Board of
California. Enter the effective date and the expiration date of the license/certificate number. If you are a
government entity, write “Exempt”.
DHCS 4468 (12/18)
Page 4 of 9
State of California
Department of Health Care Services
Health and Human Services Agency
11. “Taxpayer Identification Number (TIN)”enter the TIN issued by the IRS. Attach a legible copy of the
IRS Form 941, Form 8109-C, Letter 147-C, Form 2363, Form SS-4, or Exemption Form 1023..
12. “Social Security Number (SSN)” if the business is a sole proprietorship not using a TIN, provide the
social security number of the sole proprietor.
13. “Ownership Interest and/or Managing Control Information (Entities)”— list all corporations,
unincorporated associations, partnerships, or similar entities having 5% or more (direct or indirect)
ownership or control interest, or any partnership interest, in the applicant/provider identified in number 1.
14. “Site Certifier” – each service site location must designate one eligible representative to be a site
certifier. The site certifier is responsible for overseeing family planning services at the location to be
enrolled. A Medical Director, MD, CNP, or CNM is eligible to certify a site. The site certifier cannot
certify multiple sites.
15. “Sublease” – if applicant subleases the location where services are being rendered or provided, attach
a copy of all sublease agreements. Agreements must include sublessor and sublessee name, address,
telephone number, and terms and conditions.
16. “Practitioners” are MDs, CNP, CNM, and Non-Physician Medical Practitioners who are enrolled in
Medi-Cal and will provide clinical family planning services under the Family PACT Program. Enter the
practitioner name, professional license number, individual NPI and indicate whether or not the person is
trained in providing Long Acting Reversible Contraceptives (LARC).
Information about the individual signing this application.
17. “Print Name of Person Signing the Application”—print the last, first, and middle name of the person
who is signing the application. The application must be signed by a person who is authorized to legally
bind the provider.
18. “Driver’s License” - enter the driver’s license or state-issued identification number and state
of issuance of the individual named in number 17. Attach a legible copy to the application.
19. “Date of Birth” - enter the date of birth of the individual named in number 17.
20. “Social Security Number” - enter the social security number of the individual named in number 17.
21. “Penalty of Perjury” - an original signature and title of the individual named in number 17 is required.
Include the city, state, and the date where the application was signed.
22. “Contact Person’s Information” - enter the last, first, and middle name, title, e-mail address, and
telephone number of the individual who can be contacted by DHCS to answer questions regarding
the application package. Failure to include this information may result in the application package
being returned deficient for item(s) that a provider can readily provide by email, fax or telephone.
Privacy Statement (Civil Code, Section 1798 et seq.)
This information requested on this form is required by the Department of Health Care Services for
purposes of identification and document processing. Furnishing the information requested on this form is
mandatory. Failure to provide the mandatory information may result in your application being delayed or
not processed.
DHCS 4468 (12/18)
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