Get the free WIC Referral Form - English

WIC Referral Form Referring Professional & Agency:Referring Agency Phone Number:Parent/guardian name:Parent/guardian DOB:Address:Phone number:Preferred language:Preferred clinic:Child\'s name:Child\'s

How to fill out wic referral form

How to fill out wic referral form

1. Obtain the WIC referral form from a WIC clinic or approved health care provider.
2. Fill out all required personal information such as name, address, contact information, and household size.
3. Provide information about income and financial situation to determine eligibility for WIC program.
4. Include information about any current health conditions or special dietary needs that may require specific assistance.
5. Sign and date the form to certify that the information provided is true and accurate.
6. Submit the completed form to the WIC clinic or approved health care provider for processing.

Who needs wic referral form?

1. Individuals who are pregnant, breastfeeding, or postpartum women.
2. Infants and children up to the age of 5 years old.
3. Families or households with low income and nutritional needs.

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What is wic referral form?

The WIC referral form is a document used to refer individuals to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). It helps identify eligible participants and facilitates their access to nutritional support and resources.

Who is required to file wic referral form?

Healthcare providers, social service agencies, and organizations that assess the eligibility of potential WIC participants are required to file the WIC referral form.

How to fill out wic referral form?

To fill out the WIC referral form, provide necessary details such as the individual's name, address, contact information, household income, and any relevant medical or nutritional information. Ensure that all required fields are completed accurately.

What is the purpose of wic referral form?

The purpose of the WIC referral form is to facilitate the enrollment of eligible individuals into the WIC program by providing the necessary information for assessment and verification of eligibility.

What information must be reported on wic referral form?

The WIC referral form must report information such as the individual's name, address, phone number, household income, family size, and any relevant health or nutritional needs.