Welcome To Wic Letter - Ohio Department Of Health
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1
2Ohio Department of Health
Welcome to WIC Letter
Dear _______________________________________________________ ,
The Women, Infants, and Children Program (
) is a health program funded by the United States Department of Agriculture.
WIC
WIC provides nutrition education, supplemental foods, and screening and referral to other health and social service agencies.
You have been determined to be eligible to receive WIC services based on your status as either a pregnant, breastfeeding,
or postpartum woman or an infant or a child under five years of age; your residence; your income; and your nutritional risk.
Your nutritional risk is:
Nutrition Goal
I have discussed my nutrition goal with the
health professional. I am agreeing to:
WIC
It is important that you keep all
nutrition education and other health care appointments.
WIC
Your next WIC clinic visit is scheduled for:
Nutrition Education and Coupon Pickup Date
Next Certification Visit Date
Service Ending Notice
a
Food will end on _____________________________________ because
the child turns age 5,
a
6 month postpartum period has ended, or
a
the breastfeeding period has ended.
Consent for Sharing Information
You are not required to consent to sharing any of the following information, but may wish to for other programs that work with WIC.
If you decide not to consent, your refusal will not in any way affect the services you receive from WIC. Any information that is shared
will be kept confidential.
A check mark below indicates you give permission to share information with that program.
Information that may be shared includes: name, address, telephone number, income, date of birth, types of shots received or due,
the dates of those shots, height, weight and blood screening values.
a
a
_______________________ Immunization Program
___________________________ Lead Program
These include the Ohio Department of Health Immunization and Lead programs.
a
a
Head Start/Early Head Start
Other __________________________________
a
a
Healthy Start/Help Me Grow/Early Start
Other __________________________________
Authorized Representative
If you are not able to be present at the WIC eligibility appointment, you may have an authorized representative act on your behalf
by completing the following statement.
I give permission for _____________________________ to bring my children to the WIC clinic. I realize that my children will have
measurements taken and may have a finger stick to check iron level. I have provided my Authorized Representative with the proper
documents and told her what to expect at a WIC appointment. If necessary, I can be reached at _________________________________.
“I have been advised of my rights and responsibilities stated on the back of this letter. I certify that the information I provided is correct
to the best of my knowledge. My
Program application information may be verified. I understand making a false or misleading
WIC
statement, or misrepresenting, concealing or withholding facts may result in my paying back the cost of food issued to me and may
result in prosecution under state and federal law.”
Signature of Participant or Guardian
WIC Effective Date
Signature of WIC Personnel
HEA 4435 (Rev. 10/05)
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