Wic Referral Form PDF Details

Navigating healthcare and nutritional support for families in California is made smoother with tools like the WIC Referral Form, a crucial document facilitated by the State of California's Health and Human Services Agency, specifically under the California Department of Public Health and the WIC Program. This form serves as a bridge for pediatric referrals, assisting patients in establishing eligibility for WIC services and ensuring they receive the appropriate referrals and nutritional support needed. Essential for cases where a therapeutic formula is prescribed, the form is meticulously divided into sections that require detailed information about the patient, including their growth metrics and nutritional assessments, hemoglobin or hematocrit levels, immunization status, breastfeeding assessment, and specific dietary needs or restrictions. Furthermore, it contains provisions for prescribing therapeutic formulas, including the type, duration, and amount, along with directions for accommodating any dietary restrictions. This comprehensive approach not only streamlines the process of receiving WIC foods and other necessary nutritional support but also integrates health coverage considerations, prompting referrals to health plans or Medi-Cal for formulas or medical foods not covered by WIC, ensuring that families have access to the resources they need for their children's health and growth.

QuestionAnswer
Form NameWic Referral Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesca cdph 247a, pediatric referral form, ca cdph pediatric, wic referral form california

Form Preview Example

State of California — Health and Human Services Agency

Pediatric Referral

California Department of Public Health — WIC Program

WIC Agency:

WIC ID#:

SECTION I: Complete this section to assist the patient with WIC eligibility, WIC services, and appropriate referrals. Whenever a therapeutic formula is prescribed, complete both Sections I and II.

PATIENT NAME:

(First)

 

 

 

(Last)

 

 

 

 

 

DATE OF BIRTH:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT HEIGHT/LENGTH:

 

CURRENT WEIGHT:

 

CURRENT BMI:

 

 

MEASUREMENT DATE:

 

BIRTH WEIGHT / LENGTH:

 

 

(within 60 days)

 

(within 60 days)

 

(within 60 days)

 

 

 

 

 

 

 

 

 

 

 

inches

 

lbs

oz

BMI percentile:

%

 

 

 

lbs

oz

inches

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEMOGLOBIN OR HEMATOCRIT TEST is required every 12 months when normal

 

 

LEAD TEST (recommended at 1–2 years of age):

 

 

 

and every 6 months when abnormal.

 

 

 

 

 

 

mcg/dL

 

 

 

 

IMMUNIZATIONS are up-to-date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hemoglobin (gm/dl) or Hematocrit (%)

 

Lab Result Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Not available

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BREASTFEEDING ASSESSMENT (birth to 12 months):

Fully breastfeeding

Never breastfed

Feeding breastmilk & formula

Discontinued breastfeeding (Date:

 

)

 

SECTION II: Complete ALL boxes below when therapeutic formula is prescribed. Incomplete information may delay issuance of WIC foods.

DIAGNOSIS:

 

 

 

 

 

 

 

 

 

Prematurity

 

GERD or reflux

Food allergy:

 

 

 

Failure to thrive

 

Dysphagia

 

Other:

FORMULA / MEDICAL FOOD:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DURATION:

 

 

months

AMOUNT:

 

 

 

oz / day

This prescription is:

New

Refill

 

 

 

 

 

NOTE: At 1 year of age, the patient will receive 13 quarts of cow’s milk in addition to therapeutic formula unless Do Not Give is checked for cow’s milk (see WIC Food Restrictions).

COMMENTS:

WIC FOOD RESTRICTIONS: The patient will receive WIC foods in addition to the formula prescribed. Please check all foods listed below that are NOT appropriate for the diagnosis.

Category

WIC Foods

Do Not

Restriction / Comment

Give

 

 

 

 

 

 

 

Infants

Baby cereal

 

 

(6–12 mo)

Baby fruit / vegetable

 

 

 

 

 

 

 

 

 

Children

Cow’s milk

 

 

(1–5 yr)

Cheese

 

 

 

 

 

 

 

 

 

 

Eggs

 

 

 

 

 

 

 

Peanut butter

 

 

 

 

 

 

 

Whole grains *

 

 

 

 

 

 

 

Cereal

 

 

 

 

 

 

 

Beans

 

 

 

 

 

 

 

Vegetables / fruits

 

 

 

 

 

 

 

Juice

 

 

 

 

 

 

 

Yogurt

 

 

 

 

 

 

* whole wheat bread, corn/wheat tortilla, brown rice, barley, bulgur, or oatmeal

HEALTH COVERAGE: Refer patient to their health plan or Medi- Cal for a medically necessary formula or medical food.

WIC only provides these products when they are NOT a covered benefit by the patient’s health plan or by Medi- Cal.

Provide patient’s health insurance information:

 

 

Check action taken:

 

 

 

 

 

 

 

 

Private insurance:

 

 

 

 

 

Submitted justification

Medi-Cal managed care:

 

 

 

 

 

 

 

 

to health plan

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

Regular Medi-Cal (fee-for-service):

Yes

No

Submitted justification

to pharmacist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the patient requires a therapeutic formula and does NOT have health insurance, check ALL boxes below that apply:

Gave formula samples

Referred to Medi-Cal

Referred to WIC

QUESTIONS: Call 1-888-942-9675 or 1-800-852-5770.

Health Professionals: Go to www.wicworks.ca.gov; click Health Care Professionals; then click WIC contacts for MDs.

COMMENTS:

HEALTH PROFESSIONAL NAME

HEALTH PROFESSIONAL SIGNATURE

 

 

 

PHONE NUMBER

 

TODAY’S DATE

 

 

 

MEDICAL OFFICE / CLINIC NAME AND LOCATION OR OFFICE STAMP

The information above is only for use by the intended recipient and contains confidential information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of the original form. This institution is an equal opportunity provider and employer.

CDPH 247A Rev 03/16 | #930029

PRINT FORM

RESET FORM

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1. The wic referral form requires certain details to be inserted. Make sure the following blanks are complete:

How one can fill in cdph pediatric referral form stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - Prematurity, GERD or reflux, Food allergy, Failure to thrive, Dysphagia, Other, FORMULA MEDICAL FOOD, DURATION, months AMOUNT, oz day, This prescription is, New, Refill, NOTE At year of age the patient, and COMMENTS with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

New, Other, and Prematurity of cdph pediatric referral form

3. Completing COMMENTS, HEALTH PROFESSIONAL NAME, HEALTH PROFESSIONAL SIGNATURE, MEDICAL OFFICE CLINIC NAME AND, PHONE NUMBER, TODAYS DATE, The information above is only for, review use disclosure or, destroy all copies of the original, CDPH A Rev, PRINT FORM, and RESET FORM is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

COMMENTS, MEDICAL OFFICE CLINIC NAME AND, and The information above is only for inside cdph pediatric referral form

Be very mindful when completing COMMENTS and MEDICAL OFFICE CLINIC NAME AND, because this is where many people make some mistakes.

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