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Get Wic Referral Form
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How to fill out the WIC referral form online
Filling out the WIC referral form online is an important step in securing nutrition assistance for eligible clients. This guide will walk you through each section of the form to ensure you complete it accurately and effectively.
Follow the steps to successfully complete the WIC referral form.
- Press the ‘Get Form’ button to download the WIC referral form and access it in your preferred document editor.
- Start by indicating whether the client is eligible for Healthy Start by checking 'Yes' or 'No'. Leave this section blank if the screening has not occurred.
- Fill in the client's name and birth date in the designated fields. This is essential information for identification.
- Optionally, complete the client's sex, mailing address, phone number, city, zip code, and social security number. For infants and children, include the parent’s or guardian’s name.
- Complete the appropriate section based on the client's status as a pregnant woman, breastfeeding woman, postpartum woman, infant, or child. Ensure all measurements are taken within the specified time frame of 60 days prior to the WIC appointment.
- If applicable, check any pertinent health problems identified, even if none have been reported, as referral to the WIC program is encouraged.
- If special formula is needed, specify the type, number of months required, and include a diagnosis. Ensure a signature from the health professional is present for the prescription.
- If nutrition counseling is required, check the box and provide details of the diet prescription or order requested.
- At the bottom of the form, have the health professional’s signature, address, and phone number completed. An office stamp is also necessary.
- After completing the form, either hand it to the client or parent/guardian for their WIC certification appointment, or send it via mail or fax to the local WIC agency.
Complete the WIC referral form online today to ensure eligible clients receive the nutrition assistance they need.
The full form of WIC is Women, Infants, and Children. This program targets the nutritional needs of these specific demographics. By participating in WIC, individuals and families can access critical resources that enhance their health and well-being, simplifying the process with the WIC referral form.
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