Online Class Registration

OFP Use Only:

Please complete the following registration form for the Family PACT Training you have selected. Do not register on behalf of somebody else.

If you have previously registered for a Family PACT Training, please check to be sure the information is correct and make any updates necessary.

Thank you!

First Name*

M

Last Name*

Title/Position

Birth Month and Day (MM/DD):*

Individual (Provider) NPI:

Degree

License Type:

License Exp Date

License Number:

Daytime or Work Phone:*

Email:*

Please create a new password:

Please re-type your new password to confirm:

1. Your Primary Profession/Discipline (Select one):*

Advanced Practice Nurse Registered Nurse Licensed Practical Nurse Pharmacist Physician Physician Assistant Health Educator Nurse Midwife Billing Agent Office Clerk Medical Assistant Other (Specify):

Other

2. Your Primary Functional Role (Select the one that best describes your role):*

Medical Director Administrator Biller Clinician (Licensed) Health Educator Medical Assistant Other (Specify):

Other

3. Is this site currently enrolled in Family PACT?*

Yes No Application in progress

3a. Site name:*

3b. Business (Site) NPI:*

3c. Site Address:*

3d. City*

3e. State:*

3f. Zip Code:*

3g. Main Phone Number:*

3h. Alternative Phone Number:

3i. Site Email:

The site certifier is responsible for oversight of the family planning services rendered at the service site(s). You must be a medical director, physician, certified nurse practitioner, or certified nurse midwife to be a site certifier.

4. Are you the site certifier? *

Yes No

4a. Complete the following section only if you are certifying a new site or if you have been identified for recertification.

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

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

2. Are the Medical Director, Physician, Certified 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.

Please provide the Site NPI, Site Name and address of site you wish to certify.
Please include full street address, city and zip code in the address field.

4b. Site NPI:*

4c. Site Name:*

4d. Site Address:*

5. Specialty Services Provided at your site (please select all that apply):*

IUC (IUD)

Birth Control Implant

Vasectomy

Tubal Ligation

Colposcopy

Other

6. Provider (Practice) Type (Select one):*

College/University Rural Health Center Community Health Center (e.g. Federally Qualified Health Center) Other Non-profit Health Center Mobile or Intermittent Clinic Hospital/Hospital-affiliated Clinic Military Health System/Veterans Health Admin. facility Private Practice (Solo/Group) County/Local Health Department Other (Specify):

Other

7. Primary Employment Setting:*

Rural Suburban/urban

8. I agree that the information provided is true and correct.*

I agree

Thank you for providing this important information.

Front Office Training