The Medical Referral Form is a form you fill out that helps identify the medical or nutritional risk factor(s) needed for enrollment in WIC. Although the Medical Referral form is not mandatory, it helps WIC serve your patients better by:
- Documenting a medical or nutritional risk to facilitate WIC enrollment
- Avoiding duplicate bloodwork and anthropometric data collection
- Assisting WIC staff to target their nutrition counseling and education
- Enabling WIC staff to conduct immunization screening and referral using the most current data
- Enabling WIC staff to follow-up on your concerns about your patient as well as your recommendations
Do I need to give values on the Medical Referral Form?
Yes. Federal rules require that WIC collect exact blood values, height and weight measurements, and immunization histories. If a Medical Referral Form says 'within normal limits', WIC must redo the measurements. WIC appreciates your taking the time to fill out the form with specific details.
Who can sign a Medical Referral Form?
A physician, nurse or nutritionist/dietitian signature is required. Please note that, as a security measure WIC cannot accept a signature stamp.
Where can I get Medical Referral Forms?
- Medical Referral Form for Women and Infants file size 1MB file size 1MB
- Medical Referral Form for Infants and Children file size 3MB
Or call 1-800-WIC-1007 to order a supply.
This information is provided by the Women, Infants and Children (WIC) Nutrition Program within the Department of Public Health .