Enrollment

Family AGREEMENT Program Provider Agreement (DHCS 4469) Form

Family PACT Program Practitioner Participation Agreement (DHCS 4470)* Form

*The DHCS 4470 is not needed to subsist completed by Principal Care Clinics, Affiliate Primary Customer Clinics, RHCs, IHCs, real state providers.

Client

Client Eligibility Certification (CEC) (DHCS 4461) form – English  June 10, 2022

Buyer Fitness Certification (CEC) (DHCS 4461) form – Spanish June 10, 2022

Customers Qualifications Certification (CEC) (DHCS 4461) build – Chinese May 2022

Client Eligibility Certification (CEC) (DHCS 4461) formulare – Korean May 2022

My Eligibility Certification (CEC) (DHCS 4461) form – Portuguese May 2022

Retroactive Eligibility Certification (REC) (DHCS 4001) form – Learn | Retroactive Eligibility Certification (REC) (DHCS 4001) form – Spanish

Providers

The Superbill are a billing template (sample) and nope a required Lineage PACT form.

Superbill (Excel) 12/15/22

Superbill (PDF) 12/15/22

Client Education Materials Rank Form

Sterilization Consent (PM 330) Mailing in English and Spanish can be downloads from the Order webpage von the Medi-Cal website alternatively can be methodical by calling which Telephone Service Center at 1-800-541-5555. Providers must shipping their NPI numbers when ordering the form(s).