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How do I fill this out?
Filling out this form is straightforward. Begin by entering the patient’s information in the designated sections. Ensure that all relevant details, especially health and nutrition concerns, are provided for accurate processing.
How to fill out the Tennessee WIC Program Referral Application?
1
Gather the required applicant information.
2
Complete the health and nutrition sections thoroughly.
3
Sign the form as the healthcare provider.
4
Submit a copy via fax or email to the local WIC office.
5
Confirm receipt and follow up if necessary.
Who needs the Tennessee WIC Program Referral Application?
1
Pregnant women seeking nutritional support.
2
Breastfeeding women needing guidance on healthy foods.
3
Postpartum women who require postpartum nutritional aid.
4
Parents of infants needing health and nutrition resources.
5
Families with children up to 5 needing assistance for better health.
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What are the instructions for submitting this form?
To submit the WIC referral form, please complete all fields accurately and ensure your healthcare provider signs the document. You can fax the filled form to your local WIC office or email it if preferred. For physical submissions, check the local WIC office address available at tn.gov/wic-clinics. Always verify with your local office for preferred submission methods and retain a copy for your records.
What are the important dates for this form in 2024 and 2025?
Important dates for WIC referrals remain consistent yearly, with periodic reviews. Ensure to stay informed about renewed eligibility requirements for 2024 and 2025. Regular updates will be provided on the Tennessee WIC website.
What is the purpose of this form?
The purpose of this form is to facilitate referrals to the Tennessee WIC Program, which provides nutritional support to eligible applicants. This program is crucial for pregnant women, breastfeeding mothers, and children up to five years old to ensure they receive necessary health benefits. Submitting this referral helps clients access vital services and resources to improve their overall health and nutrition.
Tell me about this form and its components and fields line-by-line.
- 1. NAME: Full name of the applicant.
- 2. DOB: Date of birth of the applicant.
- 3. PATIENT PHONE #: Contact number of the applicant.
- 4. PRIMARY LANGUAGE: Preferred language of the applicant.
- 5. HEIGHT/LENGTH: Current height or length of the applicant.
- 6. WEIGHT: Current weight of the applicant.
- 7. HCT OR HGB: Health screening results for hemoglobin or hematocrit.
- 8. ESTIMATED DATE OF DELIVERY: Due date if the applicant is pregnant.
- 9. NUTRITION & HEALTH CONCERNS: Details on the applicant's health and nutrition concerns.
- 10. OFFICE/CLINIC NAME: Name of the healthcare provider's office.
- 11. PHONE #: Contact number for the healthcare provider.
- 12. FAX #: Fax number for the healthcare provider.
- 13. EMAIL: Email address of the healthcare provider.
- 14. PHYSICIAN'S SIGNATURE: Signature for verification by the healthcare provider.
What happens if I fail to submit this form?
Failing to submit this form can result in delays or a complete lack of access to WIC benefits for eligible families. It is essential that all required fields are completed accurately to facilitate swift processing.
- Delayed Benefits: Without the form submission, applicants may experience delays in receiving necessary nutritional assistance.
- Denial of Eligibility: Incomplete submissions may lead to disqualification from the WIC program.
- Lack of Support Services: Not submitting the form means missing out on vital health and social services referrals.
How do I know when to use this form?
- 1. Pregnancy Referrals: For referring pregnant women who require nutritional guidance.
- 2. Breastfeeding Support: For mothers who need support and education during breastfeeding.
- 3. Infant Nutrition: To ensure healthy growth for infants through WIC resources.
- 4. Child Nutrition: To assist children under five in accessing nutritious food.
- 5. General Nutrition Concerns: For individuals with identified health or nutrition risks.
Frequently Asked Questions
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What information do I need to fill out?
You will need to fill out applicant details, health concerns, and healthcare provider information.
Is the form compliant with regulations?
Yes, the WIC referral form complies with state requirements for nutritional assistance.
Can I print the form after filling it out?
Yes, you can print the filled-out form directly from PrintFriendly.
What if I make a mistake on the form?
You can easily go back and edit any fields before downloading the final version.
Is assistance available for filling out the form?
For assistance, consult with a healthcare provider or WIC office.
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