Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency

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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 it by email or mail to:
email: ProviderServices@dhcs.ca.gov
Mail: Department of Health Care Services
Office of Family Planning
MS 8400
P.O. Box 997413
Sacramento, California, 95899-7413
Please read all the instructions included in the application package carefully and complete each item
requested. Incomplete application packages will be returned.
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’s enrollment in the Family PACT program is dictated by
W&I Code, Section 24005(t)(1) through (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.
Providers are required to submit their NPI with each application package. Providers are required to
attach a copy of the CMS/National Plan and Provider Enumeration System (NPPES) confirmation for
each NPI listed in the application package.
Service Location. 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 set forth in the Family
PACT Policies, Procedures and Billing Instructions (PPBI) Manual. All Family PACT services shall be
rendered at the enrolled service location(s) only. All information on the application must match the
information on file in the Medi-Cal’s Provider Master File database.
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.
DHCS 4468 (4/17)
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