Form DH 3075 at a glance
What it is: Form DH 3075, the Florida WIC Program Medical Referral Form, has the Signature/Title of Health Professional: I refer this client for WIC eligibility determination.
Where and when to file: Mail/fax the completed form to the local WIC agency address shown in the bottom left corner of the form, or give it to the client or parent/guardian to bring to the WIC certification appointment.
A filled-in Form DH 3075 example: a health professional refers a 3-year-old
How to fill out Form DH 3075, box by box
Complete the appropriate shaded section
Complete the appropriate shaded section for the client. The WIC appointment may be recorded at the top of the form.
Is this client eligible for Healthy Start?
Check YES if the client has been screened and is eligible for Healthy Start.
Check NO if the client is not eligible for Healthy Start.
Leave blank if the client has not been screened.
Eligibility for Healthy Start does not affect a client's eligibility for WIC.
Client's Name and Birth Date, and optional information
Complete the client's name and birth date.
The client's sex, mailing address, phone number, city, zip code, and the parent's or guardian's name for infants and children are optional information.
For Pregnant Women
Pregnant Women: Complete the height in inches and the weight measurements and the date they were taken, no more than 60 days before the client's WIC appointment.
For pregnant women, complete the hemoglobin or hematocrit value and the date the value was taken. There is no limit on how old the bloodwork data can be, as long as the measurement was taken during the current pregnancy.
Complete the expected date of delivery, the date of the client's first prenatal visit, and the prepregnancy weight.
For Breastfeeding and Postpartum (Non-Breastfeeding) Women
Breastfeeding Women (eligible up to one year after delivery) and Postpartum Women-Non-Breastfeeding (eligible up to 6 months after delivery/termination of pregnancy): Complete the height in inches and weight measurements and the date they were taken, no more than 60 days before the client's WIC appointment.
For breastfeeding and postpartum women, complete the hemoglobin or hematocrit value and the date the value was taken. There is no limit on how old the bloodwork data can be, as long as the bloodwork is taken after delivery of the most recent pregnancy.
Complete the actual date of delivery, the date of the first prenatal visit, and the weight measurement at the last prenatal visit.
For Infants and Children less than 24 months of age
Infants and Children less than 24 months of age: Complete the infant's birth weight and birth length in inches.
Complete the current height in inches and weight measurements and the date they were taken, no more than 60 days before the client's WIC appointment.
For infants and children less than 24 months of age, complete the hemoglobin or hematocrit value and the date the value was taken. A bloodwork value is required once during infancy between 6 to 12 months of age (preferably between 9 to 12 months of age) and once between 1 to 2 years of age (preferably 6 months from the infant bloodwork value).
For Children 2 to 5 years of age
Children 2 to 5 years of age: Complete the current height in inches and weight measurements and the date they were taken, no more than 60 days before the client's WIC appointment.
For children 2 to 5 years of age, complete the hemoglobin or hematocrit value and the date the value was taken. A bloodwork value is required once a year unless the value is abnormal (< 11.1 hemoglobin or < 33% hematocrit), then a bloodwork value is required in 6 months.
Check all that apply
Check any health problem that you have identified.
Even if you have not identified a health problem, refer the client to the WIC program, even if nothing is checked in Check all that apply. For High venous lead level (3.5 mcg/dl or more), enter the Lead level and the Date Taken. Specify the Medical condition, the Food allergy, the Current or potential breastfeeding complications, Other, or the Recent major surgery, trauma, burns.
Nutrition Counseling Requested
If you would like a nutritionist to counsel your client on a specific diet, check the box and specify the diet prescription or diet order requested.
Give this completed form
Give this completed form to the client or parent/guardian to bring to the WIC certification appointment or mail/fax the form to the local WIC agency address shown in the bottom left corner of the form.
Signature/Title of Health Professional and office stamp
Complete the shaded area at the bottom of the form with the signature of the health professional taking the measurement or his/her designee and the office address and phone number. Stamp the form with the office stamp or the health professional's stamp. The Signature/Title of Health Professional and the Date go in that shaded area.
More rules for Form DH 3075
All shaded areas must be completed in order for the form to be processed.
If possible, please provide a copy of the immunization record for infant and child clients.
Parent or Guardian: Please bring a copy of your baby's/child's shot record to the WIC office.
Sources
[1] Form DH 3075 (6/22), Florida WIC Program Medical Referral Form, Florida Department of Health, WIC Program (the Official source link on this page).
