California Wic Form PDF Details

In the State of California, a crucial component of ensuring optimal health outcomes for both mothers and infants revolves around comprehensive nutritional and health support services, prominently facilitated through the California Women, Infants, and Children (WIC) Program. This program meticulously designed by the California Department of Public Health, seeks to bridge the gap in nutritional counseling and support for pregnant, breastfeeding, and postpartum women, along with infants facing health risks due to nutrition-related issues. The WIC referral forms, differentiated for pregnant and postpartum/breastfeeding women, constitute a foundational step in this process, requiring healthcare providers to furnish detailed patient information including health status, medical conditions, and prescribed medications or supplements. This meticulous documentation aims to empower WIC program staff to conduct an informed assessment of the patient's health needs and align program benefits effectively. However, it is emphasized that completion of the referral form does not automatically ensure eligibility for WIC benefits, as patients must meet specific program criteria. Moreover, these forms underscore the State’s commitment to equality and non-discrimination in service provision, adhering to federal laws that prohibit discrimination based on race, color, national origin, sex, age, or disability, thereby enshrining principles of inclusivity and equal opportunity in accessing health support services.

QuestionAnswer
Form NameCalifornia Wic Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescalifornia wic form, ca wic form pdf, ca wic referral, ca wic form

Form Preview Example

State of California—Health and Human Services Agency

WIIC REFERRAL FORPREGNANT WOMENAN

Health Care Provider:

California Department of Public Health

CALIFORNIA WIC Program

Please provide the information requested below for your patient. This information will be used by our program staff to assess your patient’s health status and to provide nutritional counseling. An incomplete referral may delay program benefits to your patient. A completed referral does not guarantee WIC Program benefits since program eligibility requirements must be met.

Patient’s name (last, first)

Address (street, city, ZIP)

Telephone number

Birthdate

WOMAN’S CURRENT (PRENATAL)

Height

 

 

ins.

 

/

 

/

 

Hemoglobin

 

 

gm/dl.

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measurement date

and / or

 

 

 

Blood test date

Weight

 

 

lbs.

 

 

 

 

 

Hematocrit

 

 

%

 

 

 

 

 

Est. date confinement

 

 

/

 

 

/

 

 

Date last preg. ended

 

 

/

 

 

/

 

 

Gravida

 

 

 

Para

 

 

 

 

Pregravid weight

 

 

 

 

 

 

 

 

lbs.

PLEASE INDICATE ANY MEDICAL CONDITIONS AFFECTING THIS WOMAN:

PLEASE LIST ANY CURRENT MEDICATIONS / SUPPLEMENTS PRESCRIBED:

Diabetes

Multiple Pregnancy

 

 

 

 

 

Hypertension

Tuberculosis

 

+PPD

 

INH

 

Previous poor pregnancy outcome / history (specify):

 

 

 

 

 

 

 

 

 

 

 

 

IMPRESSIONS / COMMENTS:

Other current or historical conditions (specify):

LOCAL WIC AGENCY

Name of physician / health care provider / group / clinic

 

 

Telephone Number:

 

 

 

 

 

IMPORTANT: Must be signed by health care provider

Date

In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.

This institution is an equal opportunity provider.

CDPH 247 REV 10/14

#930028

 

State of California—Health and Human Services Agency

CALIFORNIA Department of Public Health

WIC REFERRAL FOR POSTPARTUM/BREASTFEEDINGI WOMENAN

California฀WIC฀Program

 

Health Care Provider:

Please provide the information requested below for your patient. This information will be used by our program staff to assess your patient’s health status and to provide nutritional counseling. An incomplete referral may delay program benefits to your patient. A completed referral does not guarantee WIC Program benefits since program eligibility requirements must be met.

Patient’s name (last, first)

Address (street, city, ZIP code)

Telephone number

Birthdate

WOMAN’S CURRENT (After Delivery)

Height

 

 

 

ins.

 

/

 

/

 

 

 

 

 

 

 

 

 

Weight

 

 

lbs.

Measurement date

Hemoglobin

 

gm/dl.

 

/

 

/

 

and/or

 

 

 

 

 

Blood test date

Hematocrit

 

%

 

 

 

 

 

 

 

 

 

 

PREGNANCY OUTCOME

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preterm

Sm. Gest.

Fetal

 

 

 

 

Delivery date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full-Term

(37 wks.)

Age

Loss

Stillbirth

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

Sex

 

Birth weight

 

 

Birth length

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

Please describe any medical conditions affecting the infant(s):

Sex

 

Birth weight

 

 

Birth length

PLEASE INDICATE ANY MEDICAL CONDITIONS AFFECTING THIS WOMAN.

PLEASE LIST ANY CURRENT MEDICATIONS/SUPPLEMENTS PRESCRIBED:

C-Section

 

Other conditions occurring during this pregnancy or delivery

 

 

 

 

Diabetes

 

(specify):

 

 

 

 

 

 

Hypertension

 

 

 

 

 

IMPRESSIONS / COMMENTS:

 

 

 

Tuberculosis

 

Other current or historical medical conditions (specify):

 

 

 

 

 

 

+PPD

 

INH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCAL WIC AGENCY

 

 

 

 

Name of physician / health care provider / group / clinic

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number:

 

 

 

 

 

 

 

 

 

 

 

 

IMPORTANT: Must be signed by health care provider

Date

In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.

This institution is an equal opportunity provider.

CDPH 247 REV 10/14

#930028