DOH-799: New York WIC Medical Referral Form

Form DOH-799 PDF Details

A separate form is required for each patient. Sections B, Cand D must be completed by a health care provider.

Patient information: this section may be completed by the health care provider, patient/parent/guardian, or WIC local agency staff.

Measurements: current height and weight measurements are to be taken no more than 60 days before the patient's WIC appointment.

Children: children are eligible for WIC up to their fifth birthday.

Pregnant women: eligible for WIC for the duration of their pregnancy and up to 6 weeks postpartum.