This is a checklist designed to help site certifiers, clinicians, and administrative
staff familiarize themselves with the Family PACT program requirements and for
Site Certifiers/Providers to successfully navigate the enrollment process to
become a Family PACT Provider. New applicants involved in the provision of
services under Family PACT are required to complete a series of trainings in
order to certify a new site or recertify an existing site (Welfare and Institutions
Code § 24005(k)).
*Note: Each group will have their own training track checklist so please make sure you are
following the correct checklist for your position/title. Site certifiers, clinicians, and administrative
staff are REQUIRED to complete the trainings outlined in these checklists.
Please review the descriptions below to pick the appropriate training track
checklist for your position/title. Please pay close attention to the timeline
mentioned as these trainings must be completed prior to enrollment into the
program.
Provider Enrollment Application Package Checklist & Site Certifier Track Training Log
Checklist
The Medical Director, Physician, Certified Nurse Practitioner or Certified Nurse Midwife who is
responsible for overseeing the family planning services rendered at the site are required to complete
these trainings to certify a site.
Clinician Track Training Log Checklist
Physicians and Non-Physician Medical Practitioners (NMPs) including Nurse Practitioners, Physician
Assistants and Certified Nurse Midwives who are NOT identified as the site certifier, but are
responsible for delivering the full range of family planning and family planning-related services
covered under the Family PACT Program will complete this track.
Administrative Track Training Log Checklist
Medical assistants (MAs) and Front Office Staff such as Office/Clinic managers, office assistants,
receptionists or those who certify clients for enrollment, deliver client education and counseling, and
manage medical records on behalf of the Family PACT Program will complete this track.
Contact Us:
•
To access the trainings, please log on to www.ofpregistration.org and create an account.
•
For questions related to any of the trainings, please email:
OFPprovidertrai[email protected].
•
For questions related to how to become a Family PACT provider, please email:
ProviderServices@dhcs.ca.gov.
•
To contact the OFP by telephone, please call: (916) 650-0414.
Provider Checklist
Phase 1:
Complete Required Online Trainings and Family PACT Orientation
The required online trainings and Provider Orientation must be completed
prior to submitting a Family PACT Application. Failure to provide
certificates of completion will result in a returned application. Please visit our
Learning Management System (LMS) at www.ofpregistration.org to access the
complete list of required trainings and training locations.
Phase 2:
Provider Enrollment Application Package
The Family PACT Program application packet contains the following forms:
•
Family PACT Program Provider Agreement (DHCS 4469)
•
Family PACT Program Practitioner Participation Agreement (DHCS
4470)
*The DHCS 4469 and DHCS 4470, if applicable, must be submitted
with the Family PACT supplemental form on PAVE.
Phase 3:
Application Approval
If your application forms are approved, you will receive your Family PACT
Welcome Letter and your initial HAP Card order in separate shipments. All
shipments should be received within eight to ten business days.
Provider Enrollment
Application Process
NAME:
TITLE:
CLINIC NAME:
DATE:
PROVIDER ENROLLMENT APPLICATION PACKAGE
TASK DESCRIPTION
INFORMATION
NEEDED
DATE
COMPLETED
Complete the Family PACT
supplemental form on PAVE.
□
Current copy of fictitious name permit,
if applicable
□ Copy of LARC training/certification or
attestation of competency
□ Copy of sublease agreements, if
applicable
Complete and upload the Family
PACT Provider Agreement (
DHCS
4469) on PAVE.
The DHCS 4469 form must be uploaded
when submitting Family PACT supplemental
on PAVE.
Complete and upload the Family
PACT Program Practitioner
Participation Agreement (DHCS
4470) for each practitioner, on
PAVE.
•
The DHCS 4470 is required
for Private Practice (Sole
Proprietors/Group Providers)
and FQHCs.
•
The DHCS 4470 is not
required to be completed by
Primary Care Clinics, Affiliate
Primary Care Clinics, RHCs,
IHCs, or government
providers
The DHCS 4470 form must be uploaded
when submitting Family PACT supplemental
form on PAVE.
□
Individual practitioner’s NPI number
already enrolled in Medi-Cal
Provider Enrollment Checklist
NAME:
TITLE:
CLINIC NAME:
DATE:
Site Certifier Track: The Medical Director, Physician, Certified Nurse Practitioner or Certified Nurse
Midwife who is responsible for overseeing the family planning services rendered at the site are
required to complete this track to certify one site.
TRAINING NOTES DATE COMPLETED
1. Fraud, Waste, Abuse
Training
2. Documenting Family
PACT Services
3. U.S. Medical Eligibility
Criteria (2016)
4. U.S. Selected Practice
Recommendations (2016)
5. Back Office Training
6. Person-Centered
Contraceptive Counseling
for Family PACT Clients
7. Family PACT Orientation
The online trainings must be completed prior to submitting a Family PACT Application. For
questions related to any of these trainings, please email: [email protected].
Site Certifier Track Training
Enrollment Checklist
NAME:
TITLE:
Clinician Track: Required for Physicians and Non-Physician Medical Practitioners (NMPs) including
Nurse Practitioners, Physician Assistants and Certified Nurse Midwives. This track is for practitioners
who are NOT identified as the site certifier. Practitioners who are in good standing with Medi-Cal
and administer family planning services on behalf of the Family PACT Program will complete this
track.
TRAININGS NOTES
DATE COMPLETED
1. Family PACT Overview
2. Back Office Training
3. Fraud, Waste, Abuse Training
4. Documenting Family
PACT Services
5. U.S. Medical
Eligibility Criteria
(2016)
6. U.S. Selected Practice
Recommendations (2016)
7. Person-Centered
Contraceptive Counseling for
Family PACT Clients
8. Optional: Family PACT
Orientation
The online trainings must be completed prior to submitting a Family PACT Application. For
questions related to any of these trainings, please email: [email protected].gov.
Clinician Track Training
Enrollment Checklist
NAME:
TITLE:
Administrative Track: Medical assistants (MAs) and Front Office Staff such as Office/Clinic
managers, office assistants, receptionists or those who certify clients for enrollment, deliver client
education and counseling and manage medical records on behalf of the Family PACT Program will
complete this track.
TRAININGS NOTES DATE COMPLETED
1. Family PACT Overview
2. Front Office Training
3. Back Office Training
4. Fraud, Waste, Abuse
Training
5. Documenting Family PACT
Services
6. Optional: Family PACT
Orientation
The online trainings must be completed prior to submitting a Family PACT Application. For
questions related to any of these trainings, please email: [email protected].gov.
Administrative Track Training
Enrollment Checklist
