DHCS 4469 (Revised 09/2024) Page 1 of 9 Family Planning, Access, Care, and Treatment Program Provider Agreement Important: • Type or print clearly in ink. An original signature is required on the last page. • Information provided must match Medi-Cal records. • Do not leave any questions or lines blank. Service Site Legal Name

Form 4669 is subject to review by the IRS. If a payor withholds less than the correct amount of tax, it is liable for the correct amount that it was required to withhold. Section 3402 requires employers to withhold income tax on payments of wages, including reclassified wages and fringe benefits subject to federal income tax withholding.

2024年8月26日 · List of PCA forms for consumers, providers and lead agencies.

2022年6月10日 · Client Education Materials Order Form. Sterilization Consent (PM 330) Forms in English and Spanish can be downloaded from the Forms webpage of the Medi-Cal website or can be ordered by calling the Telephone Service Center at 1-800-541-5555. Providers must supply their NPI number when ordering the form(s).

Fax the application and agreement to 651-431-7465. MHCP accepts only faxed applications and agreements. Complete this form online, print and then fax to MHCP. Complete at least all bolded fields to enroll an individual PCA. We will return incomplete forms to you.

information is to be used to determine eligibility for all Public Health Insurance Programs. I understand that program officials may verify information on this form. I also understand that if I intentionally misrepresent my income, I may have to repay benefits received and may be subject to prosecution under State law. Applicant’s Signature

2024年10月10日 · DHCS 4469 Family PACT Provider Agreement DHCS 4470 Family PACT Practitioner Participation Agreement. Last modified date: 10/10/2024 1:38 PM. Get Help in Your Language ...

2025年3月7日 · To find a form or document, use DHS – Searchable document library (eDocs) and search by the number. PCA Assessment and Service Plan, DHS-3244. Supplemental Waiver PCA Assessment and Service Plan, DHS-3428D. Added fields for the start and end date of the service agreement (SA).

Complete all fields to enroll an individual personal care assistant or complete your request using the Minnesota Provider Screening and Enrollment (MPSE) portal. If submitting by fax, complete this form online, print and then fax to Minnesota Health Care Programs (MHCP). An incomplete form will delay processing of this application.

Are you enrolled in Medi-Cal? Has your contact information changed in the past two years? Give your local county office your updated contact information so you can stay enrolled. Find your local county office. Am I Eligible? © 2025 Family PACT | All Rights Reserved.