Registration


Back Office Staff Training

 

OFP Use Only:

Please complete the following registration form for the Family PACT Provider Orientation training. You may register to attend yourself or to certify a site in the Family PACT Program. 

First Name*
M
Last Name*
Title/Position
Birth Month and Day (MM/DD):*
Individual (Provider) NPI:
Degree
License Type:
License Number:
Daytime or Work Phone:*
Email:*
Please create a new password:
Please re-type your new password to confirm:
Is this site currently enrolled in Family PACT?*
Site name:*
Business (Site) NPI:*
Site Address:*
City*
State:*
Zipcode:*
Main Phone Number:*
Alternative Phone Number:
Site Email:
Your Primary Profession/Disipline (Select one):*
Other
Your Primary Functional Role (Select the one that best describes your role):*
Other
Provider (Practice) Type (Select one):*
Other
Speciality Services Provided at your site (please select all that apply):*
Other
Primary Employment Setting:*
Are you applying to certify or recertify a site? The site certifier is responsible for oversight of the family planning services rendered at the service site(s).*

Complete the following section only if you are certifying a new site.


You may register for the Provider Orientation Training to certify a site if you:

1.  Have enrolled in Medi-Cal and are in good standing, or are pending Medi-Cal enrollment, and

2.  Have submitted a Family PACT applicaiton package, and

3.  Are the medical director, physician, nurse practitioner, or certified nurse midwife responsible for overseeing the family planning services to be rendered at the site to be enrolled is eligible to certify the site. Site certifiers shall sign a statement affirming responsibility. 


If you do not satisfy the above requirements at the time of registration, you will be attending the in person orientation for informational and training purposes only and will not receive a certificate of attendance.

Please provide the Site NPI, Site Name and address of site you wish to certify.
Please include full street address, city and zipcode in the address field.
Site NPI:*
Site Name:*
Site Address:*
I agree that the information provided is true and correct.*
Thank you for providing this important information.

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