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Wic pediatric referral form

WIC Pediatric Referral Form - San Francisco Department of Public ... - vchca 2025

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The document is a referral form from the California Department of Public Health's WIC Agency, designed to assist healthcare providers in determining WIC eligibility and services for pediatric patients. It includes sections for patient information, health assessments, dietary needs, and referrals for therapeutic formulas or medical foods. The form emphasizes the importance of accurate data collection to ensure appropriate nutritional support and outlines necessary actions regarding health coverage and food restrictions.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section I, which includes the patient's name, current height, weight, and BMI. Ensure these measurements are within the last 60 days for accuracy.
Complete the hemoglobin or hematocrit test results and lead test information as required. Indicate if immunizations are up-to-date.
In the breastfeeding assessment section, select the appropriate option that reflects the patient's feeding status.
If applicable, check any conditions for soy requests under Section I before moving to Section II.
In Section II, provide a diagnosis and specify the formula or medical food prescribed along with its duration and amount.
Check all WIC food restrictions that apply to ensure compliance with dietary needs.
Finally, fill in health coverage details and submit any necessary justifications before signing and dating the form.

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How to get proof of WIC benefits in California?

Use the free California WIC App on your smart phone. Get a printout at your WIC office. Look at your store receipt from your last shopping trip. Ask the cashier or customer service desk at the store to print out your WIC Food Balance.

How do I get approved for WIC in California?

You may qualify for California WIC if you: Have a child or care for a child under age 5; and. Have low-to-medium income or receive Medi-Cal, CalWORKs (TANF), or CalFresh (SNAP) benefits; and. Live in California.

What is the WIC program in San Francisco?

WIC is federally funded and administered through the San Francisco Department of Public Health (DPH) to provide valuable benefits for families with children, including: Food assistance: WIC provides an average of $62 per person per month for purchasing healthy food.

What is WIC called in California?

The Women, Infants and Children (WIC) Division administers the California WIC program. This program helps families across the state by providing nutrition education, breastfeeding support, healthy foods and referrals to health care and other community services.

How to apply for WIC in SF?

How to apply? Call or visit one of our WIC Clinics to make an appointment. Start your WIC application online. Ask your doctor if they can send a referral to WIC.

Are WIC and CalFresh the same?

On average, WIC appointments typically last between 30 minutes to an hour.

What is WIC on health form?

WIC is the Special Supplemental Nutrition Program for Women, Infants, and Children. WIC provides free healthy foods, breastfeeding support, nutrition education and referrals to other services, to support you and your family.

WIC Pediatric Referral Form - San Francisco Department of Public ... - vchca 2025

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