Form Cdph 4461 PDF Details

Are you a new business owner in California? If so, you will need to register with the California Department of Public Health (CDPH) by submitting Form CDPH 4461. This form is used to collect information about your business, including its name, address, and contact information. You will also need to provide details about your products and services.Registration with CDPH is required for all businesses operating in California, so be sure to submit Form CDPH 4461 as soon as possible.Failure to register may result in penalties from the CDPH. For more information on registering your business, visit the CDPH website at

Form NameForm Cdph 4461
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesCA_FamilyPactAp p_English family pact state of california health access programs form

Form Preview Example

State of California—Health and Human Services Agency

California Department of Public Health




Client identification number

This form is the property of the State of California, California Department of Public Health, Office of Family Planning, and cannot be changed or altered.

Please print answers to all questions. The questions about your family size, income, and health care insurance are to determine if you are eligible for Family PACT Program services.

Providers must keep a copy of this form in the client’s medical record. (See PPBI, Client Eligibility Certification Form Completion Section for code determinations.)

Code areas are for Provider use only.

Do you currently receive Medi-Cal benefits or services?

Do you have a Medi-Cal Benefits Identification Card (BIC)?

BIC number

Issue date



Do you have health care insurance for family planning services? (Private insurance, Health Maintenance Organization (HMO), Managed Care Plan, Student Health Insurance, etc.)

Do we need to keep your family planning services confidential from your partner, spouse, or parent? How may we contact you if we need to talk to you about something?










Provider Use Only—CODE

First name

Middle name

Last name

Suffix (Jr., Sr.)

Is your current name the same as your name at birth? If no, print your name at birth below.



First name at birth

Middle name at birth

Last name at birth

Suffix (Jr., Sr.)

Number of live births


Male Female

Provider Use


County of residence

Social security number

Provider Use Nine-digit ZIP code


Mother’s first name

Date of birth (mm/dd/yyyy)

//_ _ _ _

Place of birth (county, if California)

Provider Use Only—CODE

State (if not California)

Provider Use Only—CODE

Country (if not USA)

Provider Use Only—CODE



























Native American



Pacific Islander




















Primary Language

































This information will be used to see if you are enrolled in any state health program. Information will also be used to monitor health outcomes and for program evaluation purposes. Your name will not be shared. Each individual has the right to review personal information maintained by the provider unless exempt under Article 8 of the Information Practices Act.

Complete eligibility information on reverse side.

CDPH 4461 (7/07)

Page 1 of 2

Eligibility Determination: Please list all family members (self, spouse, and children) living in your household and supported by the family income. List the source of any earned or unearned income and the amount of income, including income from employment, self-employment, tips, commissions, pensions, social security, child and/or spousal support, ongoing insurance payments, disability, Veterans Affairs, unemployment benefits, etc.


Relationship to You


Source of Income

Gross Monthly Income

(Before taxes or deductions.)


Family size:

Total family income $

I declare under penalty of perjury that the information I have given on this form is true, correct, and complete. I understand that the giving of false information may make me ineligible for this program.

Signature (or mark) of applicant


Signature of witness to mark or interpreter


Provider certification:


Eligible for Family PACT Program

Ineligible for Family PACT Program (Give applicant Fair Hearing Rights.)

Medi-Cal client eligible for Family PACT verified:

Limited scope

Unmet share-of-cost

Based upon the information provided by the applicant and according to state and federal requirements, I certify that the applicant identified on this Client Eligibility Certification is eligible to receive family planning services under the Family PACT Program. If ineligible, the client has received a copy of this form which includes the Fair Hearing Rights.

Print name













Reason code (see Provider



Annual Certification: If client is decertified (no longer eligible)




















Fair Hearing Rights

Any applicant for, or recipient of, services under the Family PACT Program has a right to a hearing conducted by the California Department of Public Health regarding eligibility or receipt of services. An applicant or recipient does not have a right to contest changes made to the eligibility standards or benefits of the Family PACT Program.

First level review: If you wish to appeal either your denial of eligibility or receipt of services, please send your name, telephone number, address, and reason why you are requesting a review to the First Level Review address below. A request for a first level review must be postmarked within 20 working days of the denial of eligibility or services. The Office of Family Planning may request additional information by telephone or in writing from the provider or the applicant before issuing a decision.

Formal hearing: You may appeal the decision of the first level review within five working days of your receipt of the decision of the first level review by sending your name, telephone number, address, and reason for the appeal to the Formal Hearing address below. At the hearing, you may be represented by a friend, relative, lawyer, or other person of your choice. A representative of the provider will be present to explain the reasons for denying eligibility. If you want an interpreter provided at the hearing, please specify the language in your letter requesting a hearing.

First Level Review

Formal Hearing

California Department of Public Health

California Department of Public Health

Office of Family Planning

Office of Regulations and Hearings

MS 8400

MS 0507

P.O. Box 997420

P.O. Box 997377

Sacramento, CA 95899-7420

Sacramento, CA 95899-7377

CDPH 4461 (7/07)

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How to Edit Form Cdph 4461 Online for Free

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This form will require particular info to be filled out, hence you should definitely take whatever time to type in what is asked:

1. To begin with, once completing the Form Cdph 4461, begin with the page containing subsequent blank fields:

Filling in segment 1 in Form Cdph 4461

2. After the previous selection of blanks is completed, proceed to type in the applicable information in these: Do we need to keep your family, No Yes Confidentiality, Provider Use OnlyCODE, First name, Middle name, Last name, Suffix Jr Sr, Is your current name the same as, Yes, First name at birth, Middle name at birth, Last name at birth, Suffix Jr Sr, Number of live births, and County of residence.

Middle name at birth, Is your current name the same as, and Suffix Jr Sr in Form Cdph 4461

3. Completing Raceethnicity, Asian Native American, Primary Language, Armenian Korean, Black Pacific Islander, Filipino White, Hispanic Other, Cantonese Tagalog, English Spanish, Hmong Vietnamese, KhmerCambodian Other, This information will be used to, CDPH, Page of, and Complete eligibility information is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Part number 3 in completing Form Cdph 4461

People who use this document frequently make mistakes while completing Filipino White in this part. Ensure you double-check what you enter right here.

4. The fourth part comes with the following form blanks to fill out: Name, Relationship to You, Age, Source of Income, Gross Monthly Income, Before taxes or deductions, Family size, Self, Total family income, I declare under penalty of perjury, Signature or mark of applicant, Date, Signature of witness to mark or, Date, and FOR PROVIDER USE ONLY.

Step # 4 in completing Form Cdph 4461

5. Since you come near to the last parts of the document, you will find a couple more things to complete. Particularly, Provider certification MediCal, Print name, Signature, Date, Annual Certification If client is, Date, Reason code see Provider Manual, Fair Hearing Rights, Any applicant for or recipient of, First level review If you wish to, Formal hearing You may appeal the, First Level Review, Formal Hearing, California Department of Public, and California Department of Public should all be filled out.

Writing part 5 of Form Cdph 4461

Step 3: Prior to addressing the next stage, ensure that all form fields have been filled in correctly. When you think it is all good, click on “Done." Sign up with us right now and easily use Form Cdph 4461, all set for downloading. All adjustments you make are preserved , allowing you to modify the file further as required. FormsPal is invested in the personal privacy of all our users; we make sure all personal data used in our system is secure.