Get the free wic medical referral form

NEW YORK STATE DEPARTMENT OF HEALTH DIVISION OF NUTRITION For WIC Use: Date Mailed/

How to fill out wic medical referral form

How to fill out a WIC medical referral form:

1. Obtain the form: Contact your local WIC office or check their website to obtain a copy of the WIC medical referral form. It is important to use the most recent version of the form for accuracy.
2. Identify the patient: Fill in the patient's personal information such as their full name, date of birth, address, and contact number. Ensure that the information provided is correct and up to date.
3. Medical history: In this section, provide detailed information about the patient's medical history. This may include any pre-existing conditions, allergies, medications being taken, and any medical treatments or surgeries undergone.
4. Doctor's information: Write the details of the healthcare professional who is providing the referral. This typically includes their name, address, phone number, and specialty.
5. Reason for referral: Indicate the reason why the medical referral is needed. This can range from specific medical conditions that require special dietary considerations to pregnancy or breastfeeding support.
6. Supporting documentation: If required, attach any relevant supporting documentation, such as medical reports or test results, to the referral form. These documents can help provide additional information to the WIC program.
7. Signature and date: Once you have completed filling out the form, sign and date it. Double-check that all the information provided is accurate before submitting it to the appropriate WIC office.

Who needs a WIC medical referral form?

1. Pregnant women: Pregnant women who meet the income guidelines and are interested in participating in the WIC program may need to provide a medical referral form from their healthcare provider.
2. Infants and young children: Infants and young children who require special dietary modifications due to certain medical conditions may also need a medical referral form from their healthcare provider.
3. Individuals with medical conditions: Anyone who has a medical condition that qualifies for additional WIC benefits, such as food modifications or medical nutrition therapy, may be required to present a medical referral form.
4. Breastfeeding women: If a breastfeeding woman is experiencing any difficulties or needs additional support, a healthcare provider may issue a medical referral form to help access specialized services through the WIC program.

Remember, the specific requirements for a WIC medical referral form may vary by state or country. It is always advisable to consult with your local WIC office or healthcare provider for accurate and up-to-date information.

For pdfFiller’s FAQs

What is wic medical referral form?

The WIC medical referral form is a document used to certify that an individual is eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) based on medical or nutritional need.

Who is required to file wic medical referral form?

Pregnant women, breastfeeding women, infants, and children under the age of five who meet certain income guidelines 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, individuals must provide information about their medical or nutritional need, as well as income and household size.

What is the purpose of wic medical referral form?

The purpose of the WIC medical referral form is to ensure that individuals who are most in need of nutritional assistance receive services through the WIC program.

What information must be reported on wic medical referral form?

The WIC medical referral form must include information about the individual's medical or nutritional need, income, and household size.

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