Form Hea 4460 - Wic Program Application - Ohio Department Of Health Page 2
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2By signing this WIC application, I agree to give proof of eligibility for
of Medicaid, and the Ohio Department of Job and Family Services to
information entered on this form and any other information asked to
exchange any information I have provided on this form to enable the
meet program rules.
departments to determine my eligibility.
I authorize any person who furnishes me with health care or medical
I understand that this application is considered without regard to race,
supplies to give the Ohio Department of Medicaid, the Ohio Department
color, national origin, sex, age, or disability.
of Job and Family Services, or the Ohio Department of Health any
By my signature below, I affirm under penalty of perjury that to the best
information related to the extent, duration, and scope of services
of my knowledge and belief all the answers on this application are true
provided to me under the Medicaid, WIC, and other medical assistance
and complete. I understand that the law provides penalty of fine or
programs.
imprisonment (or both) for anyone convicted of accepting assistance he
I also authorize the Ohio Department of Health, the Ohio Department
or she is not eligible to receive.
Signature of applicant who completed this form
Date of signature
Signature of person who helped complete this form
Date of signature
AGENCY USE ONLY
*
Pregnancy Verification
Medical statement attached
Medical chart location (office name)
Patient name and number
Telephoned (name)
Agency/Business
Call date
Verification statement
Identification Verification
*
Document type or number
Name (Circle one— I C P N B )
Present
*
Exempt
*
Document type or number
Name (Circle one— I C P N B )
Present
*
Exempt
*
Document type or number
Name (Circle one— I C P N B )
Present
*
Exempt
*
Document type or number
Name (Circle one— I C P N B )
Present
*
Exempt
Medical chart location (office name)
*
Income Verification
Verification attached (county department of job and family services, employer, other agencies)
Check those that apply
Economic unit size
*
*
*
*
*
Food Assistance
Medicaid
Refugee
OWF
Disability Financial Assistance
*
Effective date
Card number
Benefits Notice/Printout
*
Provider Information Line
*
MITS or EBT Portal
Verification statement used
Statement date
Income amount
*
*
Weekly
Bi Weekly
(document/check stub/letter)
$
*
*
*
*
Yes
No
Semimonthly
Monthly
Telephoned (name)
Agency/Business
Call date
Confirmed or other information
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
Proof of Residence
*
*
*
*
*
Ohio License/ID
Utility/credit bill
WIC Reminder Card
Medical card/JFS document
Other___________________________________
WIC personnel signature
Date
This institution is an equal opportunity provider.
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