Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Page 4
Download a blank fillable Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9State of California
Department of Health Care Services
Health and Human Services Agency
“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.
“Legal Name” is the name listed with the Internal Revenue Service (IRS).
2.
“Business Name” is the name of the provider if different from that listed in number 1.
3.
“Business Telephone Number” is the primary business telephone number used at the business
address. A beeper number, cell phone, answering service, pager, facsimile machine, biller or billing
service, or answering machine shall not be used as the primary business telephone.
4.
“Business Email Address” is the primary business email used at the business address.
5.
“Business Facsimile” is the fax used at the primary business address.
“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”.
6.
“Business Address” is the actual business location including the street name and number, room or
suite number or letter, city, county, state, and nine-digit ZIP code. A post office or commercial box is
not acceptable.
7.
“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.
8.
“Mailing Address” is the location at which the provider wishes to receive general DHCS
correspondence.
9.
“License Number” enter the license/certificate number, or other approval to provide health care, of
the provider. Attach a legible copy of the license, certificate, or approval. Enter the effective date
and the expiration date of the license/certificate number, or other approval. If you are a government
entity, write “Exempt”.
10.
“Taxpayer Identification Number (TIN)”enter the TIN issued by the IRS under the name of the
provider. Attach a legible copy of the IRS Form 941, Form 8109-C, Letter 147-C, Form 2363, or
Form SS-4 (Confirmation Notification).
11.
“Social Security Number” if the business is a sole proprietorship not using a TIN, provide the social
security number of the sole proprietor. Attach a legible copy to the application.
12.
“Driver’s License” enter the driver’s license or the state issued identification number and state of
issuance of any individual named in number 1. Attach a legible copy to the application. The driver’s
license or state-issued identification number shall be issued within the 50 United States or the
District of Columbia.
13.
“Date of Birth” enter the date of birth of the individual named in number 1, if applicable. If not
applicable, enter N/A.
14.
“Additional Service site(s)” are the addresses the provider is requesting to enroll or are enrolled in
Family PACT. List the business sites, other than the one listed in number 1, at which Family PACT
services will be provided.
7
Page 2 of
DHCS 4468 (4/17)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dhcs 7098 - California Pagsusuri Upang Manatiling Malusug - Health And Human Services Agency
Legal
Form Dhcs 7021 - California Financial Eligibility Work Sheet - Health And Human Services Agency
Legal
Form Dhcs 7098 - California Staying Healthy Assessment (tagalog) - Health And Human Services Agency
Legal
Form Dhcs 5085 - California Designation Of Administrative Responsibility - Health And Human Services Agency
Financial
Form Dhcs 7098 - California Staying Healthy Assessment (tagalog) - Health And Human Services Agency
Legal
Related Categories
Parent category: Legal