Get the free WIC Med Ref Form for Infants and Children revised 2011.docx. Image - clintonhealth

NEW YORK STATE DEPARTMENT OF HEALTH DIVISION OF NUTRITION For WIC Use: Date Mailed/ Given Date Rec d Apt Date WIC ID # WIC MEDICAL REFERRAL FORM FOR INFANTS and CHILDREN Child s Last Name (Print):

How to fill out wic med ref form

How to fill out the WIC Med Ref form:

1. Start by carefully reading the instructions provided on the form. It is crucial to understand the requirements and guidelines before beginning the filling process.
2. Begin by providing your personal information. This usually includes your name, address, contact details, and other necessary identification information. Make sure to write legibly and accurately.
3. Next, indicate the purpose of the form. Specify whether it is a new application, renewal, or any other relevant category, as specified on the form.
4. If applicable, provide information about your household members who are applying for WIC benefits. This typically includes names, ages, and relationships.
5. Complete the financial section by providing details about your income, expenses, and any other pertinent financial information required. This information helps determine your eligibility for WIC benefits.
6. Consult with your healthcare provider to fill out the medical referral section. The form may require the provider's details, such as their name, address, and phone number. They may also need to provide information about medical conditions and dietary needs that justify your eligibility for specialized WIC benefits.
7. Make sure to review the completed form thoroughly. Check for any errors, missing information, or discrepancies before submitting it.
8. Once you have verified everything, sign and date the form. Some forms may require the signature of a healthcare provider or any other designated authority. Make sure to follow the instructions provided.

Who needs a WIC Med Ref form:

1. Pregnant women: If you are currently pregnant, the WIC Med Ref form may be required to assess your nutritional needs during this crucial period. It helps ensure you receive appropriate assistance and specialized food items.
2. Postpartum women: Women who have recently given birth may need to complete the WIC Med Ref form to receive nutritional support during the postpartum period. This helps promote the health and well-being of both the mother and the baby.
3. Infants and children: The WIC Med Ref form may be necessary for infants and children up to the age of five who require additional nutritional support due to specific medical conditions or dietary restrictions.
4. Individuals with medical conditions: If you or a member of your household has a medical condition that affects dietary needs, the WIC Med Ref form allows healthcare providers to recommend specialized food items based on those nutritional requirements.

It is important to note that the specific eligibility criteria and requirements may vary depending on the region or country where you are applying for WIC benefits. Therefore, it is advisable to consult the relevant local WIC office or healthcare provider for accurate and up-to-date information.

For pdfFiller’s FAQs

What is wic med ref form?

WIC Med Ref form is a form used to report changes in medical expenses for participants in the Special Supplemental Nutrition Program for Women, Infants, and Children.

Who is required to file wic med ref form?

Participants in the WIC program who experience changes in their medical expenses are required to file the WIC Med Ref form.

How to fill out wic med ref form?

The WIC Med Ref form can be filled out by providing accurate information about the changes in medical expenses, including documentation if required.

What is the purpose of wic med ref form?

The purpose of the WIC Med Ref form is to ensure that participants receive the appropriate level of benefits based on their updated medical expenses.

What information must be reported on wic med ref form?

Participants must report any changes in medical expenses, including costs related to doctors' visits, prescriptions, medical procedures, and other health-related expenses.

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