Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Page 2
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9State of California
Department of Health Care Services
Health and Human Services Agency
Provider Orientation. New Family PACT providers and/or new provider locations will be provisionally
certified for enrollment into the Family PACT program after the provider is enrolled in Medi-Cal and until
an eligible representative attends a legislatively mandated provider orientation as determined by DHCS.
A provider must attend an orientation within six (6) months of the date of initial Family PACT enrollment
for the provisional certification to be lifted. If a provider does not attend an orientation within six (6)
months of the date of initial Family PACT enrollment, that provider and/or provider location will be
disenrolled from the Family PACT program.
Providers who are enrolled in Medi-Cal, in good standing, or are pending Medi-Cal enrollment, and who
have submitted a Family PACT application may register for a provider orientation to certify a site for
enrollment.
The medical director, physician, nurse practitioner, or certified nurse midwife 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
Records Retention. Providers must maintain legible copies of all initial and updated applications
(DHCS 4468) and initial and updated provider agreements (DHCS 4469) at the provider site.
Reporting a Change of Information. Providers are responsible for notifying the DHCS Provider
Enrollment Division within 35 days of any change in previously submitted information. 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 to Participate in the Family
PACT Program (DHCS 4468) 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. On-site visits and attempts at corrective action may be made prior to disenrollment. 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.
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 2
DHCS 4468 (4/17)
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