The California WIC form is a vital document used by health care providers to refer pregnant and postpartum women to the Women, Infants, and Children (WIC) program. This form collects essential information to assess the health status of patients and ensure they receive appropriate nutritional counseling. Timely and complete submissions of the form can help prevent delays in program benefits, making it crucial for health care providers to fill it out accurately.
To get started on the referral process, please fill out the form by clicking the button below.
The California WIC form plays a crucial role in supporting the nutritional needs of women during pregnancy and postpartum. This form is designed for healthcare providers to gather essential information about their patients, including personal details such as name, address, and birthdate. It also requires specific health metrics, like height, weight, hemoglobin levels, and pregnancy outcomes. By documenting any medical conditions and medications, the form helps assess the health status of the woman and her infant. It is important to note that while a completed referral is necessary for accessing WIC benefits, it does not automatically guarantee eligibility. The form also emphasizes the need for a healthcare provider's signature, ensuring that the information provided is accurate and complete. Additionally, the WIC program adheres to federal non-discrimination policies, promoting equal access for all individuals regardless of their background.
State of California—Health and Human Services Agency
WIIC REFERRAL FORPREGNANT WOMENAN
Health Care Provider:
California Department of Public Health
CALIFORNIA WIC Program
Please provide the information requested below for your patient. This information will be used by our program staff to assess your patient’s health status and to provide nutritional counseling. An incomplete referral may delay program benefits to your patient. A completed referral does not guarantee WIC Program benefits since program eligibility requirements must be met.
Patient’s name (last, first)
Address (street, city, ZIP)
Telephone number
Birthdate
WOMAN’S CURRENT (PRENATAL)
Height
ins.
/
Hemoglobin
gm/dl.
Measurement date
and / or
Blood test date
Weight
lbs.
Hematocrit
%
Est. date confinement
Date last preg. ended
Gravida
Para
Pregravid weight
PLEASE INDICATE ANY MEDICAL CONDITIONS AFFECTING THIS WOMAN:
PLEASE LIST ANY CURRENT MEDICATIONS / SUPPLEMENTS PRESCRIBED:
❒ Diabetes
❒ Multiple Pregnancy
❒ Hypertension
❒ Tuberculosis
+PPD
INH
❒ Previous poor pregnancy outcome / history (specify):
IMPRESSIONS / COMMENTS:
❒Other current or historical conditions (specify):
LOCAL WIC AGENCY
Name of physician / health care provider / group / clinic
Telephone Number:
IMPORTANT: Must be signed by health care provider
Date
In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
This institution is an equal opportunity provider.
CDPH 247 REV 10/14
#930028
CALIFORNIA Department of Public Health
WIC REFERRAL FOR POSTPARTUM/BREASTFEEDINGI WOMENAN
CaliforniaWICProgram
Address (street, city, ZIP code)
WOMAN’S CURRENT (After Delivery)
and/or
PREGNANCY OUTCOME
Preterm
Sm. Gest.
Fetal
Delivery date
Full-Term
(37 wks.)
Age
Loss
Stillbirth
1.
❒
Sex
Birth weight
Birth length
2.
Please describe any medical conditions affecting the infant(s):
PLEASE INDICATE ANY MEDICAL CONDITIONS AFFECTING THIS WOMAN.
PLEASE LIST ANY CURRENT MEDICATIONS/SUPPLEMENTS PRESCRIBED:
❒ C-Section
❒ Other conditions occurring during this pregnancy or delivery
(specify):
❒ Other current or historical medical conditions (specify):
Telephone number:
Completing the California WIC form requires careful attention to detail. This form is essential for ensuring that individuals receive the necessary nutritional support. To facilitate a smooth process, follow the steps outlined below to accurately fill out the form.
The California WIC form is designed to collect essential information about pregnant women and postpartum/breastfeeding women. Health care providers fill out this form to help assess the health status of their patients. The information gathered is used by WIC program staff to provide nutritional counseling and support. It is important to note that while the form aids in the application process, completing it does not guarantee that a patient will receive WIC benefits, as eligibility requirements must still be met.
The form requires various details about the patient, including:
Providing complete and accurate information is crucial, as any omissions may delay program benefits for the patient.
The WIC form must be completed by a health care provider. This can include physicians, nurse practitioners, or other qualified health professionals. Their signature is required to validate the information provided, ensuring that it meets the program's standards for assessment and eligibility.
Eligibility for the WIC program is based on several factors, including income level, residency, and nutritional risk. After the form is submitted, WIC program staff will review the information to determine if the applicant meets these criteria. It is important for applicants to be aware that even with a completed form, eligibility is not guaranteed until the review process is complete.
If the WIC form is incomplete, it may lead to delays in processing the application. Incomplete information can hinder the assessment of the patient's health status and nutritional needs. Therefore, it is essential for health care providers to ensure that all required fields are filled out accurately before submitting the form.
Individuals who believe they have experienced discrimination while accessing WIC services can file a complaint. Complaints can be submitted in writing to the USDA, Director, Office of Adjudication, located at 1400 Independence Avenue, SW, Washington, D.C. 20250-9410. Alternatively, complaints can be made by calling toll-free at (866) 632-9992. For those who are hearing impaired or have speech disabilities, the Federal Relay Service can be contacted at (800) 877-8339 (Voice) or (800) 845-6136 (Spanish).
Incomplete Patient Information: Failing to provide complete details such as the patient's name, address, or birthdate can lead to delays. Each section must be filled out accurately to ensure timely processing.
Missing Medical History: Omitting important medical conditions or current medications can affect the assessment of the patient's eligibility. It is crucial to indicate any relevant health issues, including diabetes or hypertension.
Incorrect Measurements: Providing inaccurate height, weight, or blood test results can misrepresent the patient’s health status. Ensure that all measurements are taken correctly and recorded with precision.
Lack of Provider Signature: The form must be signed by a healthcare provider. Without this signature, the referral will not be considered valid, which could prevent the patient from receiving benefits.
When navigating the California Women, Infants, and Children (WIC) program, several important documents often accompany the WIC referral forms. Each of these forms serves a specific purpose in ensuring that participants receive the necessary support and resources. Below is a list of some commonly used forms in conjunction with the California WIC referral.
These forms collectively ensure that the WIC program operates smoothly and effectively, providing vital support to pregnant women, new mothers, and young children. Understanding each document's role can significantly enhance the experience for those seeking assistance through this essential program.
The California WIC form for pregnant women shares similarities with the Medicaid Application form. Both documents require detailed personal information, including the applicant's name, address, and contact details. They aim to assess eligibility for health and nutrition-related benefits. The Medicaid Application specifically focuses on financial and medical eligibility, while the WIC form emphasizes nutritional counseling and health status. Both forms necessitate verification by a healthcare provider, underscoring the importance of professional endorsement in the application process.
Another document akin to the California WIC form is the Supplemental Nutrition Assistance Program (SNAP) application. Like the WIC form, the SNAP application collects personal and household information to determine eligibility for nutritional assistance. Both forms require applicants to disclose any medical conditions or special circumstances that might affect their eligibility. The SNAP application, however, is broader in scope, addressing food assistance for a wider demographic, while WIC specifically targets women, infants, and children.
The California WIC form also resembles the Temporary Assistance for Needy Families (TANF) application. Both documents serve to assess financial need and provide support to low-income families. The WIC form focuses on health and nutrition for pregnant women and new mothers, whereas TANF provides cash assistance and services for families in need. Each application requires documentation from healthcare providers to validate claims, ensuring that applicants receive the appropriate support based on their circumstances.
Additionally, the Child Health and Disability Prevention (CHDP) Program application shares commonalities with the California WIC form. Both documents prioritize the health and well-being of children and mothers, requiring detailed health assessments. The CHDP application emphasizes preventive health services for children, while the WIC form focuses on nutritional support for women and children. Both applications require healthcare provider signatures to confirm the accuracy of the information provided, reinforcing the role of medical professionals in these processes.
Lastly, the California Department of Public Health’s Maternal and Child Health (MCH) program referral form is similar to the WIC form. Both forms collect information regarding the health status of women and children, aiming to provide necessary health services and nutritional guidance. The MCH referral form may cover a broader range of health services, while the WIC form is specifically tailored to nutritional counseling and food assistance. Both require healthcare provider verification, emphasizing the importance of accurate health assessments in securing benefits.
When filling out the California WIC form, it is essential to provide accurate and complete information. Below are some important dos and don’ts to keep in mind:
Misconceptions about the California WIC form can lead to confusion regarding its purpose and requirements. Here are four common misunderstandings:
Understanding the California WIC form is essential for both healthcare providers and patients. Here are some key takeaways to keep in mind when filling out and using this form: