Get Health Access Programs Family Pact Program Client Eligibility Certification Form

This guide provides clear and step-by-step instructions for filling out the Health Access Programs Family Pact Program Client Eligibility Certification Form online. By following these instructions, you will ensure that your application is completed correctly and efficiently.

Follow the steps to successfully complete your form online.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin with the client identification number section at the top. This number is essential for tracking your application.
3. Answer the question about receiving Medi-Cal benefits or services by selecting yes or no.
4. If you have a Medi-Cal Benefits Identification Card, provide the issue date and the card number.
5. Indicate whether you have health care insurance for family planning services. Make sure to provide details if applicable.
6. Assess confidentiality needs by marking whether you require your family planning services to be kept confidential from a partner or parent.
7. Complete your personal information, including first name, middle name, last name, and names at birth where applicable.
8. Provide your date of birth and place of birth, along with your social security number.
9. Answer questions regarding your race/ethnicity and primary language, selecting from the provided options.
10. List all family members living in your household, along with their relationship to you, age, source of income, and gross monthly income.
11. Calculate and enter your total family income and declare the truthfulness of the information provided by signing the form.
12. Be sure to save any changes you’ve made. After completing your form, you can download, print, or share it as needed.

Complete your forms online accurately to ensure your eligibility for the Family PACT Program.