Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Page 5

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State of California
Department of Health Care Services
Health and Human Services Agency
15.
“Practitioners” are all practitioners (medical doctors, certified nurse midwifes, nurse practitioners,
physician assistants) who will be providing clinical family planning services under the Family PACT
program. Enter the practitioner name. Enter the license type (MD, DO, CNM, NP, PA). Enter the
practitioners individual NPI.
16.
“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.
17.
“Printed Name of Applicant or Provider”—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.
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.
Enter the date of birth of the individual named in number 17.
20.
Enter the social security number of the individual named in number 17.
21.
An original signature of the individual named in number 17 is required. Also provide the title of the
person signing the application. Include the city, state, and the date where and when the application
was signed.
22.
To assist in the timely processing of the application package, enter the name, 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.
7
Page 3 of
DHCS 4468 (4/17)

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