Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Page 9

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15. Practitioners Please attach a separate sheet of paper for any additional practitioners not listed
below.
Practitioner Name
License Type
Professional License Number
Individual NPI
Practitioner Name
License Type
Professional License Number
Individual NPI
16. Ownership Interest and/or Managing Control Information (Entity)
In the table below, 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.
Check here if this section does not apply
Entity Legal Business Name
Percentage of Ownership
NPI Number (If Applicable)
or Control
0%
Entity Legal Business Name
Percentage of Ownership
NPI Number (If Applicable)
or Control
0%
Information about the Individual Signing this Application
17. Print name of provider or person signing the application on behalf of the provider.
18. Driver’s license or state-issued identification
19. Date of Birth
20. Social Security Number
number and state of issuance.
21. I declare under penalty of perjury under the laws of the State of California that the foregoing
information in this document, in the attachments are true, accurate, and complete to the best
of my knowledge and belief. I declare that I have the authority to legally bind the applicant or
provider pursuant to CCR, Title 22, Section 51000.30(a)(2)(B).
Signature of provider or person on behalf of the applicant or provider
Title
Executed at:
on
(City)
(State)
(Date)
22. Contact Person’s Information
Check here if you are the same person identified in item 18. If you checked the box, provide only
Contact Person’s Name:
the email address and telephone number below.
Preferred Method of Contact
Telephone
(middle)
(first)
Mail
Email
(last)
E-mail address
Telephone number
Title/Position
7
DHCS 4468 (4/17)
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