Form WIC-41 "Nj Wic Health Care Referral (Women)" - New Jersey

What Is Form WIC-41?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2016;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form WIC-41 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form WIC-41 "Nj Wic Health Care Referral (Women)" - New Jersey

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NEW JERSEY WIC HEALTH CARE REFERRAL
FOR
PREGNANT WOMAN
BREASTFEEDING WOMAN (Up to 1 Year Postpartum)
NON-BREASTFEEDING WOMAN (Up to 6 Months Postpartum)
Name
Birthdate
/
/
Address
Telephone Number
Women, infants and children
MUST be present at every WIC
ANTHROPOMETRIC AND LABORATORY DATA
certification appointment.
Height and weight measurements must be taken <30 days prior to WIC appointment.
Bring:
At least ONE blood test of Hemoglobin, Hematocrit or Erythrocyte Protoporphyrin (EP) is needed
∙Proof of your family's income
to determine nutritional risk of all women. The blood test must be taken <90 days prior to WIC
∙Proof of where you live
appointment.
∙Proof of ID for every person
PREGNANT WOMEN need blood test which was done during pregnancy.
∙Health care referral form filled
POSTPARTUM WOMEN (breastfeeding and non-breastfeeding) need blood test which was done
out
after delivery.
∙Immunization records of
infant/child
Blood Test Date
Hemoglobin
Hematocrit
EP
Lead (if available)
Other
g/dl
/
/
gm/dl
%
CALL for an appointment with
Height
Pre-Pregnancy Weight
WIC office checked:
(Healthcare provider:
inches
lbs.
Check WIC office for patient.)
# Wks. Gest.
Measurement Date
Weight
Blood Pressure
FIRST
Burlington County
PRENATAL
/
/
lbs.
/
mm/Hg
609-267-4304
CHECK-UP
Children’s Home Society
# Wks. Gest.
Measurement Date
Weight
Blood Pressure
MOST
of NJ
RECENT
lbs.
/
/
/
mm/Hg
609-498-7755
CHECK-UP
East Orange
MEDICAL HISTORY
973-395-8960 (8963)
Delivery Date
Woman’s Weight Just Prior
# Weeks Gestation at
Gloucester County
to Delivery
Delivery
Estimated
856-218-4116
lbs.
/
/
Actual
Jersey City
Date Last Pregnancy Ended
No. Previous Pregnancies
No. Previous Live Births
201-547-6842
/
/
Newark
Check all of the following which apply and give a brief
973-733-7628
Explanation
explanation:
North Hudson
_________________________________
Hx of low birth weight infant(s) (<5.5 lbs.)
201-866-4700
Hx of premature infant(s) (<37 weeks gestation)
_________________________________
NORWESCAP
Hx of infant(s) >9 lbs at birth
908-454-1210
_________________________________
Hx of miscarriage(s)/stillbirth(s)/abortion(s)
Ocean County
_________________________________
732-341-9700 X 7520
Hx of or planned C-section
_________________________________
Multiple pregnancy or recent multiple birth
Passaic
973-365-5620
Medical problems (e.g. Diabetes, Hypertension,
_________________________________
Preeclampsia, Eclampsia)
Plainfield
_________________________________
908-753-3397
Disability which may compromise adequacy of diet
_________________________________
Social or environmental condition which may
Rutgers
973-972-3416
compromise adequacy of diet
_________________________________
Substance use (e.g. alcohol, drugs, cigarettes, pica)
St. Joseph
_________________________________
973-754-4575/4730
Vitamin/mineral supplement or medicine prescription
Special formula prescription and medical reason for
TriCounty/Gateway CAP
_________________________________
Main Office:
its necessity
_________________________________
856-451-5600
Other pertinent health/medical data
Atlantic Office:
609-246-7767
AUTHORIZATION RELEASE
Camden Office:
I, the undersigned, give permission to my provider to give the WIC Program any required medical information.
856-225-5050
Signature of Patient Being Referred
Insurance Carrier and Member ID Number
Trinitas
908-994-5141
Signature of Physician or Health Professional
Date
VNA
732-471-9301
OR
Name and Address of Physician or Clinic (Print or Stamp)
STATEWIDE
1-800-328-3838 (24 Hrs.)
Telephone Number:
WIC-41
APR 16
This institution is an equal opportunity provider.
NEW JERSEY WIC HEALTH CARE REFERRAL
FOR
PREGNANT WOMAN
BREASTFEEDING WOMAN (Up to 1 Year Postpartum)
NON-BREASTFEEDING WOMAN (Up to 6 Months Postpartum)
Name
Birthdate
/
/
Address
Telephone Number
Women, infants and children
MUST be present at every WIC
ANTHROPOMETRIC AND LABORATORY DATA
certification appointment.
Height and weight measurements must be taken <30 days prior to WIC appointment.
Bring:
At least ONE blood test of Hemoglobin, Hematocrit or Erythrocyte Protoporphyrin (EP) is needed
∙Proof of your family's income
to determine nutritional risk of all women. The blood test must be taken <90 days prior to WIC
∙Proof of where you live
appointment.
∙Proof of ID for every person
PREGNANT WOMEN need blood test which was done during pregnancy.
∙Health care referral form filled
POSTPARTUM WOMEN (breastfeeding and non-breastfeeding) need blood test which was done
out
after delivery.
∙Immunization records of
infant/child
Blood Test Date
Hemoglobin
Hematocrit
EP
Lead (if available)
Other
g/dl
/
/
gm/dl
%
CALL for an appointment with
Height
Pre-Pregnancy Weight
WIC office checked:
(Healthcare provider:
inches
lbs.
Check WIC office for patient.)
# Wks. Gest.
Measurement Date
Weight
Blood Pressure
FIRST
Burlington County
PRENATAL
/
/
lbs.
/
mm/Hg
609-267-4304
CHECK-UP
Children’s Home Society
# Wks. Gest.
Measurement Date
Weight
Blood Pressure
MOST
of NJ
RECENT
lbs.
/
/
/
mm/Hg
609-498-7755
CHECK-UP
East Orange
MEDICAL HISTORY
973-395-8960 (8963)
Delivery Date
Woman’s Weight Just Prior
# Weeks Gestation at
Gloucester County
to Delivery
Delivery
Estimated
856-218-4116
lbs.
/
/
Actual
Jersey City
Date Last Pregnancy Ended
No. Previous Pregnancies
No. Previous Live Births
201-547-6842
/
/
Newark
Check all of the following which apply and give a brief
973-733-7628
Explanation
explanation:
North Hudson
_________________________________
Hx of low birth weight infant(s) (<5.5 lbs.)
201-866-4700
Hx of premature infant(s) (<37 weeks gestation)
_________________________________
NORWESCAP
Hx of infant(s) >9 lbs at birth
908-454-1210
_________________________________
Hx of miscarriage(s)/stillbirth(s)/abortion(s)
Ocean County
_________________________________
732-341-9700 X 7520
Hx of or planned C-section
_________________________________
Multiple pregnancy or recent multiple birth
Passaic
973-365-5620
Medical problems (e.g. Diabetes, Hypertension,
_________________________________
Preeclampsia, Eclampsia)
Plainfield
_________________________________
908-753-3397
Disability which may compromise adequacy of diet
_________________________________
Social or environmental condition which may
Rutgers
973-972-3416
compromise adequacy of diet
_________________________________
Substance use (e.g. alcohol, drugs, cigarettes, pica)
St. Joseph
_________________________________
973-754-4575/4730
Vitamin/mineral supplement or medicine prescription
Special formula prescription and medical reason for
TriCounty/Gateway CAP
_________________________________
Main Office:
its necessity
_________________________________
856-451-5600
Other pertinent health/medical data
Atlantic Office:
609-246-7767
AUTHORIZATION RELEASE
Camden Office:
I, the undersigned, give permission to my provider to give the WIC Program any required medical information.
856-225-5050
Signature of Patient Being Referred
Insurance Carrier and Member ID Number
Trinitas
908-994-5141
Signature of Physician or Health Professional
Date
VNA
732-471-9301
OR
Name and Address of Physician or Clinic (Print or Stamp)
STATEWIDE
1-800-328-3838 (24 Hrs.)
Telephone Number:
WIC-41
APR 16
This institution is an equal opportunity provider.