Connecticut WIC Certification Medical Referral Form
This file is the Connecticut WIC Certification and Medical Referral Form for infants and children. It is used by health care providers to assess nutrition risks and document health data for WIC participants. This form ensures proper coordination of nutrition services and health information sharing.
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How do I fill this out?
To fill out the Connecticut WIC Certification Form, collect all required personal information first. Next, ensure that health data is accurately recorded, including weights, heights, and assessments. Finally, review the form for completeness before submitting it to the WIC office.
How to fill out the Connecticut WIC Certification Medical Referral Form?
1
Gather all necessary personal information.
2
Record accurate health data including weight and length.
3
Ensure all participant information fields are filled out.
4
Get signatures from the health care provider and WIC Certified Professional.
5
Review the form for completeness before submission.
Who needs the Connecticut WIC Certification Medical Referral Form?
1
Parents or guardians of infants and children who need WIC benefits.
2
Health care providers conducting well-child visits.
3
Nutritional staff overseeing participant health.
4
WIC Program administrators for record-keeping.
5
Community health workers assisting families with access.
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What are the instructions for submitting this form?
To submit the Connecticut WIC Certification Form, please send the completed document to your local WIC office. You may submit it via email at wicinfo@ct.gov or fax it to (555) 555-5555. If you prefer physical submission, you can visit your nearest WIC center located at 123 WIC Rd, Hartford, CT 06103.
What are the important dates for this form in 2024 and 2025?
For the WIC Certification Form, ensure that health data is collected within specific timeframes: 9-12 months, 15-18 months, 2 years, 3 years and 4 years of age. It's important to keep track of any follow-up visits as specified by WIC regulations. Regular updates can help maintain eligibility and access to nutrition services.
What is the purpose of this form?
The primary purpose of the Connecticut WIC Certification Form is to assess the nutritional needs of infants and children. This form helps ensure that eligible participants receive appropriate assistance through the WIC program. Additionally, it facilitates communication between health care providers and WIC staff to coordinate care and support.
Tell me about this form and its components and fields line-by-line.
- 1. Participant ID: A unique identifier for each WIC participant.
- 2. Child's Name: The full name of the child receiving WIC services.
- 3. Parent/Guardian: The name of the child's parent or guardian.
- 4. Address: The residential address of the participant.
- 5. Date Collected: The date when health measurements were taken.
- 6. Weight: The recorded weight of the child for health assessment.
- 7. Length or Height: The height or length measurement of the child.
- 8. Body Mass Index (BMI): Calculated BMI based on height and weight.
- 9. Hemoglobin: Hemoglobin level for anemia screening.
- 10. Hematocrit: Hematocrit level for anemia determination.
What happens if I fail to submit this form?
Failing to submit this form can lead to delays in processing WIC benefits. Without the necessary information, WIC staff may not be able to provide adequate support. It's crucial to ensure timely submission to avoid interruptions in nutrition services.
- Delayed Benefits: Without submission, participants may not receive timely WIC benefits.
- Inadequate Health Assessment: Missing data can hinder proper health evaluations.
- Loss of Services: Failure to complete the form may lead to loss of eligibility for WIC services.
How do I know when to use this form?
- 1. Initial WIC Application: Required for families applying for WIC for the first time.
- 2. Health Assessments: Used by health providers to document health data during assessments.
- 3. Recertification: Necessary for participants who need to renew their WIC benefits.
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