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WIC Medical Referral Form

DOH-799 (2/18) Page 1of 2 NEW YORK STATE DEPARTMENT OF HEALTHWIC ProgramWIC Medical Referral FormThis form maybe used to refer patients to the WIC Program and to communicate changesin patient health information. The information provided on this form will be used by a WICnutritionist to determine nutrition care and provide nutrition counseling. A separate form is required for each patient. Sections B, C and D must be completed by ahealth care reverse side for additional IDWIC LOCAL AGENCY STAMPP atient Name_____ Date of Birth ____ /____ /____ Sex_____Street Address_____Apt.

Complete the estimated date of delivery, number of fetuses, and pre-pregnancy weight. Postpartum/Breastfeeding Women: Non-breastfeeding postpartum women are eligible for WIC for up to 6 months after delivery/termination.

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