Formula samples Submitted justification Referred to Medi-Cal to health plan Referred to WIC Other: Regular Medi-Cal (fee-for-service) If the patient requires a therapeutic formula and does NOT have health insurance, check ALL boxes below that apply: Submitted justification to pharmacist QUESTIONS: Call 1-888-942-9675 or 1-800-852-5770. Health Professionals: Go to www.wicworks.ca.gov; click Health Care Professionals; then click WIC contacts for MDs. The information above is only for use.
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How to fill out the Cdph 247a Form online
Filling out the Cdph 247a form online is easy and straightforward. This guide will walk you through each section of the form to ensure that you provide complete and accurate information.
Follow the steps to successfully fill out the Cdph 247a Form online.
- Click the ‘Get Form’ button to acquire the form and open it in your preferred editor.
- In Section I, enter the patient's full name, current height and weight within the last 60 days, and date of birth. Calculate and note the patient's current Body Mass Index (BMI) and BMI percentile. If applicable, provide the date for the hemoglobin or hematocrit test results.
- Indicate the breastfeeding assessment status for infants under 12 months. Choose from the options such as 'fully breastfeeding,' 'never breastfed,' or 'discontinued breastfeeding', along with the relevant date if applicable.
- If a soy request for the child is being made, indicate the condition by checking the appropriate box. Complete the immunization status and lead test information if required.
- In the comments section, include any additional relevant details. Enter the health professional's name, clinic name, signature, contact number, and today's date.
- If the therapeutic formula is prescribed, proceed to Section II. Document the diagnosis and any WIC food restrictions necessary for the patient's health.
- Complete the formula or medical food section, detailing the prescribed duration, amount, and whether the prescription is new or a refill.
- Finally, provide the health coverage information, checking any action taken regarding formula samples or referrals. Ensure the entire form is filled out accurately before proceeding.
- After filling out the form, you can save changes, download, print, or share the completed document as needed.
Complete your Cdph 247a Form online today for a smooth filing process.
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