Wic Referral Form PDF Details

In some states, wic referral forms are required in order to receive benefits from the WIC program. However, in other states, a simple letter from your health care provider may be enough. In order to find out what is required in your state, it is best to contact your local WIC office. The WIC Referral Form can be used to authorize services and/or products for a participant or client of the Women, Infants and Children (WIC) Program. The form must be completed by a healthcare professional and should include the: Participant's name; Name of authorized service(s) or product(s); Date of service/product delivery; Provider's signature and stamp (if available). services provided under

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

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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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