Healthy Families Program - A healthier tomorrow starts today!

EE And CAA Forms.

ITP Form

These are the forms required to start The Invitation to Participate (ITP), which is the registration process for organizations interested in becoming an Enrollment Entity (EE) for the Healthy Families and Medi-Cal for Families Programs.

When completed, mail your completed ITP form, applicable State License or tax status verification, completed W-9, signed EE and CAA agreement(s) to:

Healthy Families EE/CAA Registration
625 Coolidge Drive, Suite 100
Folsom, CA 95630

or fax to: 1-916-673-4500 Attn: EE/CAA Liaison

Add/Remove Certified Application Assistant (CAA)

Use this form if you represent an Enrollment Entity (EE), and want to add or remove a Certified Application Assistant (CAA). Please contact the EE/CAA Liaison Help Line at 1-800-279-5012 or email: ee-caaliaison@MAXIMUS.com, Monday through Friday, 8:30 a.m. to 5:00 p.m. with any questions.

Add/Remove CAA Form (pdf 37 KB)

When completed, mail to:

Healthy Families Program,
EE/CAA Liaison,
625 Coolidge Drive, Suite 100
Folsom, CA 95630

or fax to: 1-916-673-4500 Attn: EE/CAA Liaison

Change of Information for Enrollment Entity (EE)

Use this form if you represent an Enrollemnt Entity (EE), and need to update the EE's contact information. Please contact the EE/CAA Liaison Help Line at 1-800-279-5012 or email: ee-caaliaison@MAXIMUS.com, Monday through Friday, 8:30 a.m. to 5:00 p.m. with any questions.

Change of Information for EE (pdf 46 KB)

When completed, mail to:

Healthy Families Program,
EE/CAA Liaison,
625 Coolidge Drive, Suite 100
Folsom, CA 95630

or fax to: 1-916-673-4500 Attn: EE/CAA Liaison

W9 Form

A completed W9 Form (pdf 240 KB) is required to register as an EE for the Healthy Families Progrm. When completed, please include with the ITP registration package. Please contact the EE/CAA Liaison Help Line at 1-800-279-5012 or email: ee-caaliaison@MAXIMUS.com, Monday through Friday, 8:30 a.m. to 5:00 p.m. with any questions.

Sub-Site Registration Form

Use this form if you represent an Enrollment Entity (EE), and need to register a new subsite for your EE. Please contact the EE/CAA Liaison Help Line at 1-800-279-5012 or email: ee-caaliaison@MAXIMUS.com, Monday through Friday, 8:30 a.m. to 5:00 p.m. with any questions.

Subsite Address Form (pdf 45 KB)

When completed, mail to:

Healthy Families Program,
EE/CAA Liaison,
625 Coolidge Drive, Suite 100
Folsom, CA 95630

or fax to: 1-916-673-4500 Attn: EE/CAA Liaison

Certified Application Assistant Agreement

This form is required before you can become a Certified Application Assistant (CAA).

CAA Agreement (pdf 58 KB)

EE Reimbursement Discontinuance

EEs that have met the eligibility requirements to receive reimbursement payments from the Healthy Families Program have the right to request NOT to receive any future payments. If an EE chooses not to receive reimbursement based on receiving grant monies or other funds from application assisted activities, an EE must complete and submit to the HFP the EE Reimbursement Discontinuance Request Form (pdf 42 KB). This form must be completed by the authorized contact for an EE. Upon receipt of this form, the Healthy Families Program will set a Do Not Pay status for the Enrollment Entity. If an EE has already submitted a written request to discontinue reimbursements, the Healthy Families Program will contact the EE to verify the information provided and/or request additional information.

Please complete and return the form to:

Healthy Families Program,
EE/CAA Liaison,
625 Coolidge Drive, Suite 100
Folsom, CA 95630

Or, you may fax the form to , attention EE/CAA Help Desk.

Research on a Reimbursement Transaction

EE's wishing to request research on a reimbursement transaction should submit a Reimbursement Research Request Form (pdf 48 KB) to Healthy Families.

Participating Plans Marketing Guidelines

A perspective Certified Application Assistant (CAA) for an Enrollment Entity (EE) must review this document.

Participating Plans Marketing Guidelines (pdf 268 KB)

Code of Conduct

A perspective Certified Application Assistant (CAA) for an Enrollment Entity (EE) must sign this document. Please contact the EE/CAA Liaison Help Line at 1-800-279-5012 or email: ee-caaliaison@MAXIMUS.com, Monday through Friday, 8:30 a.m. to 5:00 p.m. with any questions.

Code of Conduct Agreement (pdf 113 KB)

Healthy Families Program
625 Coolidge Drive, Suite 100
Folsom, CA 95630

or fax to: 1-916-673-4500