California Pediatric Referral Form Instructions
This file provides detailed instructions for health professionals on how to complete and submit the California Pediatric Referral Form for the WIC Program. It includes sections on patient information, therapeutic formula prescriptions, health coverage, and professional recommendations.
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How do I fill this out?
Filling out this form accurately is essential for assisting patients with WIC eligibility and referrals. Begin by filling out the patient’s details and medical information in Section I. If a therapeutic formula is prescribed, ensure to complete both Sections I and II with the necessary details.
How to fill out the California Pediatric Referral Form Instructions?
1
Enter the patient's personal and medical details in Section I.
2
Complete the breastfeeding assessment and lead test sections.
3
Provide diagnosis and prescribed formula details in Section II if applicable.
4
Include health coverage information and actions taken.
5
Sign and date the form, and provide professional contact information.
Who needs the California Pediatric Referral Form Instructions?
1
Pediatricians needing to refer patients to the WIC program.
2
Healthcare providers prescribing therapeutic formulas to children.
3
Health professionals assessing a child's growth and development.
4
WIC agencies processing the eligibility and service referrals for children.
5
Parents needing support and resources for their child's nutritional and health needs.
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What are the instructions for submitting this form?
Submit the completed form to the appropriate WIC agency. Forms can be sent via email, fax, or delivered in person to the designated WIC office. Ensure all sections are filled out accurately and the form is signed and dated by the health professional. Retain a copy for your records. For more details on submission, contact WIC at 1-888-942-9675 or 1-800-852-5770.
What are the important dates for this form in 2024 and 2025?
The important dates for this form in 2024 and 2025 include annually scheduled updates in March and October.
What is the purpose of this form?
The purpose of this form is to provide health professionals and WIC agencies with a structured way to refer pediatric patients for WIC services and therapeutic formulas. It ensures that all necessary medical and personal information is collected to determine the patient's eligibility and needs. This form facilitates communication between healthcare providers and WIC agencies to support the health and nutritional requirements of children in California.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for the patient's name, date of birth, current height/length, weight, and BMI.
- 2. Breastfeeding Assessment: Assesses the patient's breastfeeding status, including measurement date, birth weight/length, and breastfeeding status.
- 3. Lab Test Results: Fields for Hemoglobin or Hematocrit test results and lead test values.
- 4. Immunizations: Checks if the patient's immunizations are up-to-date.
- 5. Diagnosis: Includes diagnosis options and fields for prescribed therapeutic formula and medical food.
- 6. Health Coverage: Captures the patient's health insurance information and any actions taken regarding medically necessary formula.
- 7. Health Professional Details: Fields for the health professional’s name, signature, phone number, and date.
What happens if I fail to submit this form?
Failure to submit this form may result in delays or denial of WIC services and therapeutic formula provision for the patient.
- Denied WIC Services: The patient may not receive the necessary WIC benefits and nutritional support.
- Delayed Medical Support: Therapeutic formula provision may be delayed, affecting the patient's health.
- Lack of Documentation: Incomplete medical records could impact the patient's overall care and follow-ups.
How do I know when to use this form?
- 1. WIC Program Referral: Use when referring patients to the WIC program for eligibility and nutritional services.
- 2. Therapeutic Formula Prescription: Required for prescribing special formulas for medical conditions.
- 3. Patient Assessments: For documenting patient assessments, current health status, and growth metrics.
- 4. Health Coverage Details: To provide information about the patient's health insurance and coverage actions.
- 5. Health Professional Recommendation: For health professionals to recommend necessary services and support.
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