Doh 132 Form PDF Details

The Department of Health's DOH 132 form serves as a critical junction in the healthcare and nutritional support framework, especially catering to infants and children within New York State’s WIC Program. This comprehensive form not only facilitates a seamless exchange of vital health information between healthcare providers and the WIC (Women, Infants, and Children) Program but also ensures the continuity of care when families transition between WIC programs. The necessity of this form arises from its detailed sections that capture essential data such as the child's birth history, current weight and height, hematology details, and immunization records. This rich dataset empowers WIC nutritionists and counselors to tailor their assistance and advice to meet the specific nutritional needs of each child. Moreover, the inclusion of specific medical diagnosis or nutritional/health risks, along with ICD-9 codes, further refines the scope of care provided. The form underscores the importance of guardian authorization for the release and exchange of medical information, highlighting the program's commitment to confidentiality and privacy. Through its structured format, the DOH 132 form exemplifies a well-thought-out tool for fostering collaborative health care, ensuring that young beneficiaries of the WIC Program receive the most appropriate nutritional support and medical care tailored to their individual needs.

QuestionAnswer
Form NameDoh 132 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswic nyc pdf, Recumbent, MMR, Hct

Form Preview Example

NEW YORK STATE DEPARTMENT OF HEALTH

For WIC

Date Mailed/

Date Rec’d

Given

 

DIVISION OF NUTRITION

Use:

Appt Date

WIC ID #

 

 

 

 

 

WIC MEDICAL REFERRAL FORM FOR

INFANTS and CHILDREN

Child’s Last Name (Print):___________________________________________ Child’s First Name: ___________________________________

Parent/Caretaker’s Name:__________________________________________ Street: _________________________ Apt: ________________

City:______________________________________ Zip:__________________ On WIC Before: Yes □

No □

Sex: M □

F □

Phone: (

) ________ ‐ ________ Child's DOB: ______/______/______ Language(s) Spoken: ___________________________________

I authorize __________________________________________________(Health Care Provider) to release the information below to the WIC Program, and I authorize the WIC

Program to release information about my infant/child to this health care provider for the purposes of coordinating his/her health care. If I need to transfer to another WIC Program, I authorize the release of this information to the transferring WIC Program. All information is considered confidential.

YOUR SIGNATURE: _________________________________________

Health Care Provider: Please complete this section.

BIRTH HISTORY:

SGA (<10th Weight for Gestational Age)

WEIGHT and HEIGHT must be less than 60 days old on the date of the

 

 

 

 

WIC appointment _____/_____/_____

 

Date Taken:

Birth Weight ______lb ______oz OR

_______kg

Current Weight _____lb _____oz OR _____kg

_____/_____/_____

 

 

 

 

Current Height/Length _____in OR ______cm

_____/_____/_____

Birth Length ________in OR ________cm

Weeks Gestation_________

Measurement Taken:

□Standing

□Recumbent (< 2 yrs)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEMATOLOGY:

 

 

Date Taken:

Provide marker IMMUNIZATION dates or attach a copy of record.

Hgb __________gm/dL OR Hct_______

______%

____/____/____

 

First

Second

Third

Fourth

Fifth

 

 

 

 

Hep

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blood Lead __________ mcg/dL at one year of age

____/____/____

B

 

 

 

 

 

 

 

 

 

 

 

 

DTP/D

 

 

 

 

 

 

 

 

Blood Lead __________ mcg/dL at two years of age

____/____/____

Tap

 

 

 

 

 

 

 

 

MMR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPECIFIC MEDICAL DIAGNOSIS OR NUTRITIONAL/HEALTH RISKS including ICD‐9 code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider's Name (Please Print):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Health Care Provider

 

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Office/Clinic:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street:

 

 

 

 

 

 

 

 

 

 

City:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #:

 

 

Fax #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date: ______/______/______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Send Completed Form To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOH‐132 (10/08)

 

 

This institution is an equal opportunity provider.

 

 

 

 

 

 

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