Get State Of Connecticut Wic Programdepartment Of Public Health Certification/medical Referral Form

The State Of Connecticut WIC Program Certification/Medical Referral Form is essential for ensuring that infants and children receive necessary nutritional support. This guide provides step-by-step instructions to help users fill out the form effectively online, ensuring proper completion for efficient processing.

Follow the steps to complete the WIC certification form online.

1. Click ‘Get Form’ button to access the form and open it in your chosen platform.
2. Complete the participant ID and family ID sections as indicated. These sections are typically filled out by WIC Program staff.
3. Fill in the child's name, date of birth, sex, parent or guardian's name, phone number, and address accurately in their respective fields.
4. Once prompted, provide health data which includes weight, length or height, body mass index (BMI), and any relevant medical conditions. Ensure that these measurements are within the specified timeframe of 60 days.
5. Indicate whether a lead test was conducted and include any relevant results regarding medications or medical concerns.
6. Your health care provider must sign and provide their title, address, and date of the examination to confirm the child's health status.
7. If applicable, the participant or guardian must complete the authorization section allowing WIC staff to access relevant medical information.
8. Complete the opportunity to register to vote section, ensuring that the parent or guardian's preference is recorded accurately.
9. Final validation should be conducted, ensuring all fields are completed. Save your changes, and prepare to download, print, or share the completed form as needed.

Ensure your child's nutritional needs are met by completing the WIC certification form online today.