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Click ‘Get Form’ to open the pawic document in the editor.
Begin by entering the Client’s First & Last Name and Birth Date in the designated fields.
Fill in the Parent/Caregiver's First & Last Name. Then, specify the Formula/Fortifier Requested along with the Amount requested (oz/day, pkg/day, or Tbsp/day).
Indicate the Intended length of use by selecting one of the options provided. If applicable, check 'Via tube feeding?' and provide any Special instructions for preparation and use.
Enter the ICD-9 Code related to the medical condition justifying this request.
Answer whether there are any WIC food restrictions. If yes, check appropriate foods and specify Length of restriction.
Complete section 4 regarding authorization for milk type if applicable, including Signature, Date, Printed Name, Medical Office/Clinic details, Telephone, and Fax.
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WIC Income Guidelines Effective Date 7/1/2024 HOUSEHOLD SIZEMONTHLY (Approx.)ANNUAL 1 $2,322 $27,861 2 $3,152 $37,814 3 $3,981 $47,767 4 $4,810 $57,7204 more rows
What makes you not eligible for WIC?
Income Standard. The state agencys income standard must be between 100 percent of the federal poverty guidelines (issued each year by the Department of Health and Human Services), but cannot be more than 185 percent of the federal poverty income guidelines.
What is the maximum income to qualify for WIC?
Verification of income would only be done when staff have reason to believe the family has other sources of income that were not reported or the familys income or family size was under reported. The following table lists what is included as gross income, and the corresponding examples of acceptable proof.
What is the income limit for WIC in PA?
WIC Income Guidelines Effective Date 7/1/2024 HOUSEHOLD SIZEMONTHLY (Approx.)Welfare 185% HB HBP 1 $2,322 $27,861 2 $3,152 $37,814 3 $3,981 $47,767 4 $4,810 $57,7204 more rows
Does WIC actually verify income?
Eligibility The gross monthly income limit for an individual is no more than $1,533 per month. For an elderly or disabled individual, the gross monthly income amount is typically no more than $1,916 per month. Monthly income eligibility limits increase with the size of the family.
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Through WIC, pregnant women, mothers, and caregivers of infants and young children learn about good nutrition to keep themselves and their families healthy!
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