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Click ‘Get Form’ to open the WIC Pediatric Referral Form in our editor.
Begin by filling out Section I. Enter the patient's name, current height, weight, date of birth, and BMI. Ensure these measurements are within the last 60 days for accuracy.
Complete the hemoglobin or hematocrit test results and lead test recommendations as applicable. Indicate if immunizations are up-to-date.
If applicable, assess breastfeeding status and provide details on any therapeutic formula prescribed in Section II. Fill in the diagnosis and specify any food restrictions.
Provide health coverage information and check actions taken regarding insurance or referrals. Include comments as necessary.
Finally, ensure that a health professional's name, phone number, signature, and today's date are included before saving or sharing the completed form.
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Where can I find my WIC family ID number in California?
Family ID Check the CA WIC App for your 9 digit Family ID. In the CA WIC App, click the 3 lines in the top left corner to open the menu. Your Family ID will be at the top of the menu.
Can I use my WIC card at self-checkout in California?
The option to enable the California WIC Card at self-check registers is up to the individual store. Call the store ahead of your visit or go to the customer service desk while in the store to ask about using the WIC card at self-checkout.
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.
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.
Can I still use my WIC card if I lost it?
What if my card is lost or stolen? Call customer service or your WIC clinic to cancel your card as soon as possible. You can get a new card at your WIC clinic. Any unused benefits for the current benefit period will be available on your new card, but any items purchased (even if not by you) cannot be replaced.
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Related links
WIC Pediatric Referral Form
Complete this form to assist the patient with WIC eligibility, WIC services, and appropriate referrals. Current Height/Length (Within 60 Days). Current Weight (
Nonresponse Card, the Neighbor Information Form, the Screener Non-Interview Form, Consent Forms,. Authorization for Transportation Form, etc.). Corrections
WIC Pediatric Referral - Health Net Provider Library
SECTION I: Complete this section to assist the patient with WIC eligibility, WIC services, and appropriate referrals. Whenever a therapeutic formula is
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