MD WIC Medical Documentation Form 2014 free printable template

Medical Documentation Form This form is federally required to ensure your patient has a medical diagnosis that requires an exempt infant formula/WIC-eligible nutritional or change to the WIC food

How to fill out MD WIC Medical Documentation Form

How to fill out MD WIC Medical Documentation Form

1. Obtain the MD WIC Medical Documentation Form from the local WIC office or download it from the official website.
2. Fill in the patient's personal information, including their name, date of birth, and WIC ID number.
3. Provide details about the medical provider: name, address, phone number, and signature.
4. Indicate the specific medical condition requiring WIC services.
5. Complete the nutritional assessment section based on the patient's health and dietary needs.
6. Attach any relevant medical records or test results that support the need for WIC services.
7. Review the form for accuracy and completeness before submission.
8. Submit the form to the local WIC office either in person or via mail as instructed.

Who needs MD WIC Medical Documentation Form?

1. Individuals who are pregnant, breastfeeding, or have young children (up to age five) and require nutritional assistance through the WIC program.
2. Healthcare providers who need to document a patient's eligibility for WIC services.
3. Families seeking nutritional support and education related to health and wellness for their children.

People Also Ask about

How much formula does WIC provide in Maryland?

Up to 104 fl oz reconstituted powder can be issued only for qualifying conditions as listed in Policy and Procedure 5.09. 1 IBP-mostly applies to infants that are breastfed and are receiving <14 fl oz of formula from WIC.

What does WIC cover in Maryland?

If you are eligible, you will receive nutrition information, breastfeeding support, referrals to other services, and foods such as: whole grain bread, tortillas, and brown rice. fruits and vegetables. dried canned beans and peas. peanut butter. cereal, milk, and 100% juice. eggs and cheese. baby food and baby cereal.

What is the Maryland WIC app?

The Maryland WIC Mobile App will give WIC participants the opportunity to view upcoming appointments, view food benefits that have been issued to them in the clinic, scan UPCs while shopping at the store to see if the UPC is a WIC Approved item or not, and provide information on locations of WIC Stores and WIC Clinics

How do I check my WIC balance in Maryland?

Call your local WIC Office or 1-800-242-4942 for assistance with your benefits.

Is WIC income based in Maryland?

Income Eligibility Income guidelines are calculated using gross (before tax) income. Check the WIC website for current guidelines. For example, a family of 2 qualifies for benefits if you have a monthly income of less than $2,607.

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What is MD WIC Medical Documentation Form?

The MD WIC Medical Documentation Form is a required form used within the Maryland Women, Infants, and Children (WIC) program to document medical necessity for WIC services and benefits.

Who is required to file MD WIC Medical Documentation Form?

Healthcare providers or organizations participating in the WIC program are required to file the MD WIC Medical Documentation Form for eligible participants to certify their need for specific services.

How to fill out MD WIC Medical Documentation Form?

To fill out the MD WIC Medical Documentation Form, providers should complete all required sections, including participant information, medical assessments, and signatures. The form must be filled accurately and submitted according to the guidelines set by the Maryland WIC program.

What is the purpose of MD WIC Medical Documentation Form?

The purpose of the MD WIC Medical Documentation Form is to establish the medical eligibility of WIC participants and to ensure that they receive the appropriate nutrition and health services based on their specific needs.

What information must be reported on MD WIC Medical Documentation Form?

The information that must be reported on the MD WIC Medical Documentation Form includes participant demographics, medical history, height and weight measurements, nutrition assessments, and provider signatures.