Get Wic Medical Referral Form

The WIC Medical Referral Form is essential for participating in the Women, Infants, and Children (WIC) program. This guide will provide you with a clear and comprehensive process to complete the form online, ensuring all necessary information is accurately submitted.

Follow the steps to effectively complete the WIC Medical Referral Form

1. Press the ‘Get Form’ button to access the WIC Medical Referral Form and open it in your preferred document editor.
2. Begin by filling in your last name and first name in the designated fields provided. Make sure these names are clearly printed.
3. Next, enter your street address, apartment number (if applicable), city, and zip code in the appropriate sections.
4. Provide a phone number with the area code in the specified format.
5. Fill in your date of birth by entering the day, month, and year.
6. Indicate whether you have been on WIC before by selecting 'Yes' or 'No'.
7. If applicable, please provide your maiden name for records.
8. List the language(s) you speak to facilitate proper communication.
9. Authorize a health care provider to release your information by writing their name in the mentioned section. Additionally, authorize the WIC Program to communicate with them.
10. Sign your name to certify that the information you have provided is accurate and complete.
11. Your health care provider will need to fill out their section, including details about the pregnancy, weight, height, and any relevant medical diagnoses.
12. After all sections are completed, save the form, then download, print, or share it as necessary.

Complete your forms online today to ensure a smooth application process!