To see if you or your family is eligible, call one of the offices listed and speak to a wic staff person. Federal register special supplemental nutrition program. The special supplemental nutrition program for women, infants, and children wic is a nutrition program for pregnant women, infants, women who are breastfeeding, postpartum women, and. Medical documentation for wic formula and approved wic. Il4443183 r0816 wic referral form printed by authority of the state of illinois 0 copies. The purpose of this system is to inform applicants, participants, and potentially eligible persons of the program availability. Division of public health f40076 082018 women, infants. Displays the participant name and id, group head for the infant, phone number, and birth and. Wic prescriptions clinical data, infants birth through. Medical documentation for formula and food please have the clientcaregiver return this completed form to the wic office or fax it to the wic office. Documentation of nutrition products from wic the following wic participant is enrolled in the medicaid program. Women, infants and children wic program forms cdph 247 a pdf pediatric referral cdph 247 b pdf wic referral for postpartumbreastfeeding women cdph 247 c pdf wic referral for pregnant women cdph 4125 pdf report concerning vendors for local agency and participant use cdph 4476 pdf participant abuse report.
Wic health partners should fill out the medical request for formula form to request wic formulas for their patients. Wic 388 provides parents with an escape mechanism to avoid the termination of parental rights by allowing the juvenile court to consider a parents changed circumstances after reunification services have been terminated. Standardized illinois early intervention referral form. Wic helps pregnant women, new mothers, and young children eat well and stay healthy. For best results, use internet explorer v11 or above to open hfs medical forms. There is no limit to how often or how much you can learn. Under the wic policy, states have discretion to specify eligible food forms eg, canned and brands and to set minimum stocking requirements at wic vendors. Fax this completed form to the wic clinic or have your patient return it to their wic clinic. When going to the interview, make sure that you are taking all the necessary documents with you to speed up screening process. A person or certain family members, who participate in other benefit programs such as snap, medicaid, or tanf, automatically meet the wic income eligibility requirements. Clients are eligible for all wic benefits, including personalized counseling with a nutritionist, and individual and group education. Bureau of the census mothers who receive wic benefits.
Search forms by namenumber, in the form field enter all or part of the form name, all of the form number, or the last portion of the form number after the hyphen e. Completed medically prescribed formula form pdf only needed if formula is prescribed to you by your doctor for nutritioneducation session. When you go shopping at a grocery store remember to bring your wic id folder along with your checksvouchers or your ewic card, depending on what the state gives you. Transition of the women, infants, and children wic program find wic provider information on the hhsc website. Because prenatal care is important in preventing health problems during pregnancy and in promoting newborn health, the program was developed to promote early and continuous prenatal care and. Wic program medical documentation infant birth to 12 months of age the wic program promotes breastfeeding for infants the. Programs, activities and employment opportunities in the illinois. If you use chrome or other browsers, you may experience technical difficulties with certain fillable pdf s, depending on your browser settings. Local wic agencies should refer to the nutrition practice guideline standardeffective nutrition education for details on requirements. Pdf download wic 2020 yearly calendar pdf mclean county wic.
Transition of the women, infants, and children wic program. It affords due process to parents while allowing for childrens right to stability and permanency. Nutrition services and administration nsa costs effective. Bfpcs should work principally in the wic clinic setting meeting women face to face. Please browse this collection of forms and publications.
General information stepbystep instructions illinois. State of illinois department of human services wic program illinois authorized wic food list grains milk meat and beans 100% whole wheat bread, buns 16 oz whole wheat pasta any shape 16 oz. Completed medically prescribed formula form pdf only needed if formula is prescribed to you by your doctor. Request forms can also be faxed to the cms division of examining and counseling at 217 5248740. Women, infants, and children wic is a federal food assistance program. Completed medically prescribed formula form pdf only needed if formula is. Wic provides whole cows milk, whole lactosefree cows milk, or soy milk. My signature below authorizes the tennessee wic nutrition staff to determine appropriate wic supplemental foods, amounts, and length of issuance for the participant. The department of state health services dshs maintains this web page, but the 84th legislature made structural changes to the health and human services system, including transferring some dshs functions to the health and human. In doing so, wic prevents more serious medical problems caused by poor nutrition. Health care provider letter children 15 years of age medical form infants up to 12 months medical form women pregnant, breastfeeding, and nonbreastfeeding postpartum medical form. Medicaid presumptive eligibility instructions for providers september 2015. The wic program provides nutrition education, health care referrals, breastfeeding support and vouchers for nutritious supplemental foods at no cost to eligible lake county residents.
Bureau of the census mothers who receive wic benefits fertility and socioeconomic characteristics in summer 1993, there were 36 million mothers 15 to 44 years old living in the united states. Wic program or lactation consultant can help you work out a plan for feeding your baby. Wic program in illinois thursday, october 11th, 2012 at 12. Issuing local agency information participant information your wic. Publication orders and fulfillment wic publications order form rev 10419. Wic publications order form wic works resource system. Wic program medical documentation child 12 months of age and older or woman complete sections a and d for all prescriptions. Please fax or email this completed form to the wic clinic or have your patient return it to their wic clinic. If you have an upcoming appointment please contact your local wic office to see what documents you may need to provide. State and federal laws protect the rights of nursing mothers and babies. To prescribe a formula or product for a child 12 months of age or older or a woman, also complete section b. Ceda operates 20 wic clinics in the chicago and suburban area and serves over 50,000 participants every month, making it the largest wic program in illinois. Public notification effective january 2016 all usda fns assistance programs must include a public notification system. This page contains a comprehensive list of idphs forms and publications organized by topic.
All requests are subject to wic approval and provisions based on program policy and procedures. Assistance for women, infants, and children or wic. Idhs 4433 s snap work requirement poster cook spanish pdf illinois 211 get connected. Wic knows that good nutrition, starting with pregnancy, provides the best possible start for babies and children to grow up strong. Il 1040 schedule il wit front r1219 printed by authority of the state of illinois web only, 1. Medical documentation is federally required to issue special formulas and some supplemental foods to wic women, infants and children who have qualifying conditions that requires the use of special formulas listed on the. The information provided on this form will be used by a wic nutritionist to determine nutrition care and provide nutrition counseling. Proof of residential address the illinois medical care card is no.
Instructions for completing the florida wic program medical referral form all shaded areas must be completed in order for the form to be processed. Wic helps you and your baby get healthy foods and healthy advice in the first years of life. If you can not find the form or publication that you are looking for, type a search term into the search tool at the top of the page. Il4444253 r1116 wic program client certification form. Illinois wic policy and procedure manualillinois wic policy and procedure manual wic certification form assessing for separate households wic income guidelines memorandum on the subject of adjunctive eliggy y,ibilitypa42 screen dated july 1, 2015 calculator general requirements policy cs 1. This form documents wic participation and the amount of formula provided in the wic food package. The program provides supplemental foods, health care referrals, and nutrition education. Such residents can receive food, nutrition education and advice, and health care referrals.
All the wic benefits are accessible in illinois through local wic clinics. This guidance is intended to be used in conjunction with the illinois wic policy and procedure manual. Wic program illinois authorized wic food list idhs 4207 pdf state of illinois department of human services. When a client needs a therapeutic formula or medical food, wic requires a completed wic medical documentation form that. Schedule il wit, illinois income tax withheld, allows you to enter your withholding information in one place and calculate total illinois withholding. Nutrious food packages and coupons are provided without cost to pregnant, postpartum, or nursing women, infants, and children. If you have questions about volume 2 policies, please contact the state wic office at 18008411410. The illinois wic program uses the wic formula and medical nutritional prescriptions form as its method for communicating and documenting special formulafood needs from the medical home to the wic agency. If you have more than five withholding forms, complete multiple copies of this schedule. Wic clinics in the united states and its territories can order free publications from the usda food and nutrition service no international orders. April 2015 once the amount of funds available to illinois for the wic program is determined. Wic vendor voluntary withdrawal form pdf to be completed and submitted by any vendor wishing to stop being an authorized vendor or in the case of the sale or closing of a business. Illinois department of revenue 2019 schedule il eeic illinois exemption and earned income credit attach to your form il 1040 il attachment no. If the child is known by another name enter it here.
View the wic eligibility guidelines for july 1, 2018 to june 30, 2019. Wic program illinois authorized wic food list idhs 4207. In order to apply for wic program in illinois, you will have to contact your local wic clinic. Illinois wic income guidelines wic office locations. Participants are provided referrals to all applicable health care programs and social services in their area. The special supplemental nutrition program for women, infants and children wic is a public health nutrition program under the usda providing nutrition education, nutritious foods, breastfeeding support, and healthcare referrals for incomeeligible women who are pregnant or postpartum, infants, and children up to age 5. Wic may be able to help if you are pregnant or breastfeeding have an infant or child up to age 5 want to improve your familys health with good nutrition meet the income guidelines below illinois wic income guidelines effective july 1, 2019 illinois wic income guidelines effective july 1, 2019. Illinois wic program nutrition practice standard explanation of wic food benefits letter july 2016 nutrition practice standards are provided to assist staff in translating policy into practice.
Infants requiring a standard milkbased or soybased formula are issued a contract formula. The illinois wic program provides the following materials to assist local wic agencies in incorporating concepts that engage the learner and meet the program expectations. Wic is a federal nutrition program that provides wic may. Wic program in illinois wic online classes, texas wic. Illinois wic policy and procedure manual issue date. State of illinois certificate of child health examination. It must be submitted along with certification of medical. To prescribe whole milk for a child 2 4 months of age or older or a woman, also complete section c. Prescriptions written on prescription pads wont be accepted. Illinois department of revenue 2019 schedule il wit attach to your form il 1040. Department of agriculture office of the assistant secretary for civil rights 1400 independence avenue, sw. Other formulas for qualifying medical diagnoses may be requested by completing this form. The completed and signed form may be dropped off at any of the assessment centers or mailed directly to the address on the form.
Check yes if the client has been screened and is eligible for healthy start. Dunn county wic program 18883325768 7152322498 7155560290 feel free to text us too. Illinois wic program management evaluation tool form date. I have read this form, or wic staff has read this form to me. All wic offices are currently open for phone appointments only. State of illinois department of healthcare and family services standardized illinois early intervention referral form please complete sections 1 through 6 of this form to refer a child to early intervention ei for eligibility determination. Proof of address if your address is different since your last appointment. Search forms illinois department of human services. I understand and agree to the above rules and agreement, and i have received a copy of these rights and responsibilities in the wic approved foods booklet. Check no if the client is not eligible for healthy start. Illinois department of revenue 2020 schedule wci withholding income tax credits information and worksheets whats new for 2020. In addition to their work in wic clinics, peer counselors should expect to make telephone contacts from home and clinic. Limited quantities are available until supply exhausted. Wic prescriptions washington state department of health.
Wic staff use only wic staff must complete section in its entirety and note commentsactions consent on file at wic medical documentation for wic formula and approved wic foods for women, infants and children doh4456 515 page 1 of 2 new york state department of health division of. Wic will accept prescriptions for foods and formula only when written on a wic medical documentation form. Wic nutritional program mississippi state department of. Retention of participants through the first five years update stephanie bess, ms, rd, ldn illinois wic nutrition services coordinator outline background and purpose description of the wic to 5 program what do we know to date results from the wic to 5 process evaluation what factors contribute to retention. Cost reporting by functional category 1 local agency nsa costs for the wic program must be broken down and reported in four functional cost categories. Oklahoma wic service is required to contract with a formula company. Wic referral form woodford county health department. If you enter an amount on form il 1040, line 25, attach a copy of your schedule il wit and all your forms w2 and 1099 showing illinois income and withholding. The california wic app will give wic participants the opportunity to view upcoming appointments, view food benefits that have been issued to them in the clinic, scan upcs while shopping at the store to see if the upc is a wic approved item or not, and provide information on locations of wic stores and wic clinics across the state of california. Medical documentation health care provider authorization for special formulas and wic supplemental food important.
Wic program wic medical referral form this form may be used to refer patients to the wic program and to communicate changes in patient health information. Wic is a federal nutrition program that provides wic may be. Complete illinois wic food list pdf list of peoria county wic stores pdf. If you are a wic participant please visit our approved food guide webpage for an expanded list of foods that have been approved through may 31, 2020. Program eligibility is determined by the following. Wic is a special supplemental food program for pregnant, breastfeeding, and postpartum women, infants, and children under five years of age. Card must be presented at the clinic for food instrument wic check issuance. For any additional form or resource needs, please contact the wic vendor relations unit at dhs. Wic food packages peoria citycounty health department. Illinois wic is special supplemental program for women, infants, and children having low household income and facing nutrition risk, as determined by a qualified health professional. All components of this form are required and must be completed by a medical provider to receive medically prescribed formulas through the. The state agency uses the illinois wic income guidelines listed below to help determine if an applicant is eligible for the wic program.