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NEW YORK STATE DEPARTMENT OF HEALTH WIC MEDICAL REFERRAL FORM FOR CHILDREN DIVISION OF NUTRITION (1 TO 5 YEARS OF AGE) APPLICANT ? CHILD: Please complete this section on your child. Child? Last Name

How to fill out wic medical referral form

How to fill out wic medical referral form?

1. Gather all necessary information and documents required for the form, such as personal identification, proof of income, and medical information of the individual who needs the referral.
2. Visit your local WIC office or healthcare provider and ask for the medical referral form.
3. Fill out the form accurately and completely, providing all the required information, including the reason for the referral and any relevant medical history.
4. Make sure to sign and date the form before submitting it.
5. Follow any additional instructions provided by your healthcare provider or the WIC office regarding the submission of the form.

Who needs wic medical referral form?

1. Pregnant women who require specialized medical care during their pregnancy.
2. Infants or young children who require medical treatment or nutrition counseling.
3. Individuals with specific medical conditions that may benefit from WIC services, such as breastfeeding support or special dietary needs.
4. Anyone receiving medical assistance and requires a referral for WIC services as part of their treatment plan.

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What is wic medical referral form?

The WIC medical referral form is a document used by the Women, Infants, and Children (WIC) program to refer participants to medical providers for specialized nutritional and health services.

Who is required to file wic medical referral form?

Participants of the WIC program who may require additional medical services or specialized nutrition guidance are required to file a WIC medical referral form.

How to fill out wic medical referral form?

To fill out the WIC medical referral form, you need to provide the participant's personal information, medical history, and the reason for the referral. The form should be completed by a WIC program staff member or a healthcare professional.

What is the purpose of wic medical referral form?

The purpose of the WIC medical referral form is to ensure that WIC participants receive appropriate medical care and specialized nutritional services based on their individual needs and health conditions.

What information must be reported on wic medical referral form?

The WIC medical referral form should include the participant's name, contact information, medical history, reason for the referral, and any relevant information about their health conditions or specialized dietary needs.