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Get CA DHCS 4461 2014

Umber This form is the property of the State of California, Department of Health Care Services, 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 this original form in your medical record. • Code areas are for Provider use only. (See PPBI, Client Eligibility Certification Form .

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