Get Patient's Name: Date Of Birth (dob): // - Ct.gov

This guide provides a comprehensive overview of how to accurately fill out the Patient's Name: Date Of Birth (DOB): // - CT.gov form. It aims to assist users in navigating each section of the form with clear, step-by-step guidance.

Follow the steps to successfully complete the form.

1. Locate and press the ‘Get Form’ button to retrieve the form, allowing you to open it in your preferred online editor.
2. Enter the patient's name in the designated field. Ensure that the name is spelled correctly and matches any legal documentation.
3. Fill in the Date of Birth (DOB) field by selecting the appropriate month, day, and year. This information is critical for identification purposes.
4. Specify the formula requested by detailing the type (e.g., powder or concentrate) chosen and the prescribed ounces per day, if applicable.
5. Complete the section on special formula instructions by indicating any specific preparation guidelines and the intended length of use.
6. Select any qualifying medical condition(s) by marking the relevant ICD code(s) from the provided list. It is important to document an actual diagnosis rather than just symptoms.
7. Indicate whether whole milk is required based on a qualifying condition, by checking 'Yes' or 'No'.
8. Check the items under WIC Supplemental Foods that are contraindicated based on the patient's medical diagnosis and provide any necessary explanations.
9. Authorize the WIC Nutrition Professional to decide on future WIC Supplemental Foods by checking the appropriate box.
10. Ensure that the healthcare provider completes and signs the form, including their printed name, contact information, and date. An original signature is required.
11. After reviews, you can save changes, download, print, or share the form as necessary for submission.

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