Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Page 6

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State of California
Department of Health Care Services
Health and Human Services Agency
FAMILY PACT APPLICATION (DHCS 4468) CHECKLIST
Please remember to include a legible copy of the following with your application package;
Verification of enrollment into Medi-Cal or Medicare (if applicable)
Driver’s license or state issued identification card(s)
TIN Verification
Social Security Card
License, Certification, or other approval
Fictitious Business Name Statement/Permit
National Provider Identifier Verification (CMS/NPPES confirmation) for each NPI listed on
the application
If you have any additional questions, please contact the Family PACT program at (916) 650-0414 or by
email at ProviderServices@dhcs.ca.gov.
DHCS 4468 4/17)
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