Get Wic Medical Referral Form

This guide provides a comprehensive overview of the WIC Medical Referral Form, outlining each component to help you complete the form accurately online. Filling out this form correctly is essential for ensuring proper health coordination for infants and children in the WIC program.

Follow the steps to fill out the WIC Medical Referral Form online.

1. Click the ‘Get Form’ button to access the WIC Medical Referral Form and open it for editing.
2. In the first section, you will find spaces for the child's last and first names. Enter the child's last name in the first blank and their first name in the second blank.
3. Next, provide the name of the parent or caretaker in the designated field, followed by their address, including street, apartment number (if applicable), city, and zip code.
4. Indicate whether the child has previously been on WIC by selecting 'Yes' or 'No.' Additionally, indicate the child's sex by marking the appropriate box (M or F).
5. Fill in the parent's or caretaker's phone number. It's important to ensure that this is accurate for communication purposes.
6. Provide the child's date of birth in the format prompted on the form and list the languages spoken by the family.
7. In the health care provider consent section, specify the name of the health care provider you authorize to release information to the WIC Program.
8. The health care provider will complete their section, including the child's birth history, weight and height, hematology results, immunization dates, and any specific medical diagnoses or nutritional risks.
9. The provider should print their name, sign the form, and provide their title and medical office or clinic details, including address and phone number.
10. After reviewing all information for accuracy, save your changes, and download the form. You should then be able to print or share the form as required.

Complete your WIC Medical Referral Form online today to ensure proper health care coordination.