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Form Ph 3151 - Wic (Women, Infants And Children) Program Referral Form - Tennessee Department Of Health

TENNESSEE DEPARTMENT OF HEALTH

WIC (WOMEN, INFANTS AND CHILDREN) PROGRAM REFERRAL

TO BE COMPLETED BY HEALTH CARE PROVIDER

To receive WIC Program benefits, applicants must be determined to have a medical or nutritional risk. The WIC

assessment includes current anthropometric measures and periodic blood screening.

Measures for pregnant,

breastfeeding and non-breastfeeding postpartum women must be taken when participants are in these categories.

Infants and children are certified for one year and measures are required at each certification and at mid-certification (6

months after date of certification). Hemoglobin or hematocrit for children is required at 9-12 months, 15-18 months,

and then yearly if normal range or at 6 months intervals if lower than WIC’s protocol. Hemoglobin or hematocrit for

women is required at prenatal and postpartum certification.

Please provide the information indicated below to assist us in assessing your patient for WIC

NAME: __________________________________________DATE OF BIRTH: _____________________________

HEIGHT OR LENGTH: _______________________________WEIGHT: __________________________________

HEMATOCRIT OR HEMOGLOBIN: _____________________DATE OF MEASURES: ________________________

ESTIMATED DATE OF DELIVERY (if pregnant) ____________

PHYSICIAN’S SIGNATURE: _____________________________________________________________________

Health Care Provider Contact Information

Name: ____________________________________________________________________________________

Address: __________________________________________________________________________________

Phone Number: _____________________________________________________________________________

PATIENT MUST TAKE THIS REFERRAL FORM TO THE LOCAL HEALTH DEPARTMENT WITHIN 60 DAYS OF THE

DATE MEASURES WERE TAKEN.

In accordance with Federal law and U.S. Department of Agriculture (USDA) 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.

PH 3151 (Rev 11/13) ED# 1000051778

RDA 150

Form Ph 3151 - Wic (Women, Infants And Children) Program Referral Form - Tennessee Department Of Health