Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Page 3
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9State 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.
This form is part of an application for enrollment or continued enrollment as a provider in the Family PACT
program. Providers must also provide additional information and documentation. 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) must also be completed for enrollment or continued enrollment. Additional
information can be found on the Family PACT website ( ) by clicking the “Providers” tab,
followed by “Provider Enrollment”.
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.
National Provider Identifier (NPI)—enter the NPI of the provider.
Enrollment Action Requested—check the action requested. Enter the date you are completing the
application.
“New Provider”—check if the provider is not currently enrolled in the Family PACT program as a provider
with an active provider number. Include the NPI for the business address indicated in item 6.
“Change of business 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. Indicate the new
business address provider under Type of Entity number 1 through number 13.
“Additional business address”—check if the provider is currently enrolled in the Family PACT program
and is requesting enrollment for an additional business location.
“New Taxpayer ID number”—check if a new Taxpayer Identification Number (TIN) was issued by the
IRS.
“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.
“Continued Enrollment”—check if the provider is currently enrolled as a Family PACT provider and has
been requested by the Department to apply for continued enrollment in the Family PACT program. Do not
check this box unless you have received notification from the Department.
“Medi-Cal Enrollment Status”—check if the provider is currently enrolled in the Medi-Cal program.
Indicate the application process status, as applicable. Attach verification if applicable.
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DHCS 4468 (4/17)
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