Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Page 7

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State of California
Department of Health Care Services
Health and Human Services Agency
FAMILY PACT PROVIDER APPLICATION
FOR STATE USE ONLY
Important:
•
Read all instructions before completing the application
•
Type or print clearly, in ink.
•
If you must make corrections, please line through, date and initial in ink.
•
Return completed forms by email or mail to:
email: ProviderServices@dhcs.ca.gov
Mail: Department of Health Care Services
Office of Family Planning
MS 8400
P.O. Box 997413 Sacramento,
California, 95899-7413
Do not use staples on this form or any attachments.
Do not leave any questions, lines, etc. blank. Enter N/A if not applicable to you.
National Provider Identifier (NPI)
Date
Enrollment action requested (check all that apply)
New Provider
Change of Ownership
Change of business address
New Tax Payer ID number
Additional business address
Continued Enrollment (Do not check this box unless
Update
you have been requested by the Department to apply
Indicate effective date
for continued enrollment in the Family PACT Program.
Medi-Cal Enrollment Status
I am currently enrolled in the Medi-Cal program at this business address and under this legal name.
(Attach Verification)
I am currently enrolled in the Medi-Cal program under a different business address and/or legal
name. (Attach Verification)
I have a pending Medi-Cal application. Application date sent:
I am not currently enrolled in the Medi-Cal program.
Type of Entity (check one)
Sole Proprietor
Indian Health Center (IC)
Government entity
Group Provider
Licensed Community/Free Clinic
Rural Health Center (RC)
Federally Qualified Health Center (FQHC)
Other
7
Page 5 of
DHCS 4468 (4/17)

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