Form Doh-132 - Wic Medical Referral Form For Infants And Children Page 3
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3NEW YORK STATE DEPARTMENT OF HEALTH
DIVISION OF NUTRITION
MEDICAL DOCUMENTATION FOR WIC FORMULA AND APPROVED WIC FOODS FOR
DRAFT
INFANTS, CHILDREN AND WOMEN
Patient’s Name _____________________________________________________ Birth Date (MM/DD/YY) ____________________________
Birth Date: (MM/DD/YY) ______________________________________________
Parent/Caretaker's First and Last Name________________________________________________________________________________________
I authorize __________________________________________________ (Health Care Provider) to release the information below to the WIC Program, and I authorize the WIC
Program to release information about me to this health care provider for the purposes of coordinating my health care. If I need to transfer to another WIC Program, I
authorize the release of this information to the transferring WIC Program. All information is considered confidential.
YOUR SIGNATURE: ___________________________________________________
Prescription is subject to WIC approval and provision based on Program policy and procedure.
Qualifying medical condition(s) including ICD-9 code: Justifies the prescription of requested formula/medical food
_____________________________________________________________________________________ ICD-9 Code________________________
WIC formula/medical food requested: _______________________________________________________________________________________
Prescribed amount per day: _______ oz/day
Special Instructions/Comments:____________________________________________________
Length of use: ______________________________________ (Prescription renewal required periodically)
The patient will receive the supplemental foods, appropriate to their WIC participant category, listed below in addition to the WIC
formula/medical food. Please indicate any supplemental foods or restrictions that would be contraindicated with the patient's medical
diagnosis.
WIC Participant
WIC Supplemental Foods
Do Not
Restrictions/Comments
Category
Available
Give
Infants (6-12 months)
Infant Cereal
Infant Food Vegetables/Fruits
Children and Women
Milk
Cheese
Cereal
Juice
Eggs
Vegetables/Fruits
Whole Wheat Bread
Beans
Peanut Butter
Canned Fish *
* "Fully Breastfeeding Women" is the only WIC participant category eligible to receive canned fish.
Provider's Name (Please Print):
Signature of Health Care Provider
Title:
Medical Office/Clinic:
Street:
City:
Zip:
Phone #:
Fax #:
Date:
/
/
This institution is an equal opportunity provider.
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