Form HEA4460 "Wic Program Application" - Ohio

What Is Form HEA4460?

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

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Ohio 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 fillable version of Form HEA4460 by clicking the link below or browse more documents and templates provided by the Ohio Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form HEA4460 "Wic Program Application" - Ohio

Download PDF

Fill PDF online

Rate (4.4 / 5) 21 votes
Page background image
Ohio Department of Health
WIC Program Application
Please answer all questions on the top portion of this page.
Parent, guardian or applicant’s name
Other parent/guardian
Telephone
Home
Work
Cell
Leave Message
Street Address
City
State
ZIP
County
Mailing address (if not the same as street address)
City
State
ZIP
Is anyone else in your household pregnant, recently had a baby, or is an infant or child under the age of 5?
Yes
No
By signing this WIC application, I agree to give proof of
and Family Services to exchange any information I have
eligibility for information entered on this form and any other
provided through the application process to enable the
information asked to meet program rules.
departments to determine my eligibility.
I authorize any person who furnishes me with health care or
I understand that this application is considered without
medical supplies to give the Ohio Department of Medicaid,
regard to race, color, national origin, sex, age, or disability.
the Ohio Department of Job and Family Services, or the Ohio
Department of Health any information related to the extent,
By my signature below, I affirm under penalty of perjury that
duration, and scope of services provided to me under the
to the best of my knowledge and belief all answers on this
Medicaid, WIC, and other medical assistance programs.
application are true and complete. I understand that the
law provides penalty of fine or imprisonment (or both) for
I also authorize the Ohio Department of Health, the Ohio
anyone convicted of accepting assistance he or she is not
Department of Medicaid, and the Ohio Department of Job
eligible to receive.
Signature of applicant who completed this form
Date of signature
Signature of person who helped complete this form
Date of signature
STOP HERE
AGENCY USE ONLY
Pregnancy Verification
Medical statement attached
Medical chart location (office name)
Patient name and number
Telephone (name)
Agency/Business
Call date
Verification statement
Identification Verification
Name (I C P N B)
Name (I C P N B)
Document type or number
Document type or number
Present
Present
Exempt
Exempt
Name (I C P N B)
Name (I C P N B)
Document type or number
Document type or number
Present
Present
Exempt
Exempt
Name (I C P N B)
Name (I C P N B)
Document type or number
Document type or number
Present
Present
Exempt
Exempt
Name (I C P N B)
Name (I C P N B)
Document type or number
Document type or number
Present
Present
Exempt
Exempt
Medicaid/OWF/SNAP verification
WIC personnel signature
Date
HEA 4460 (Revised 4/19)
This institution is an equal opportunity provider.
Ohio Department of Health
WIC Program Application
Please answer all questions on the top portion of this page.
Parent, guardian or applicant’s name
Other parent/guardian
Telephone
Home
Work
Cell
Leave Message
Street Address
City
State
ZIP
County
Mailing address (if not the same as street address)
City
State
ZIP
Is anyone else in your household pregnant, recently had a baby, or is an infant or child under the age of 5?
Yes
No
By signing this WIC application, I agree to give proof of
and Family Services to exchange any information I have
eligibility for information entered on this form and any other
provided through the application process to enable the
information asked to meet program rules.
departments to determine my eligibility.
I authorize any person who furnishes me with health care or
I understand that this application is considered without
medical supplies to give the Ohio Department of Medicaid,
regard to race, color, national origin, sex, age, or disability.
the Ohio Department of Job and Family Services, or the Ohio
Department of Health any information related to the extent,
By my signature below, I affirm under penalty of perjury that
duration, and scope of services provided to me under the
to the best of my knowledge and belief all answers on this
Medicaid, WIC, and other medical assistance programs.
application are true and complete. I understand that the
law provides penalty of fine or imprisonment (or both) for
I also authorize the Ohio Department of Health, the Ohio
anyone convicted of accepting assistance he or she is not
Department of Medicaid, and the Ohio Department of Job
eligible to receive.
Signature of applicant who completed this form
Date of signature
Signature of person who helped complete this form
Date of signature
STOP HERE
AGENCY USE ONLY
Pregnancy Verification
Medical statement attached
Medical chart location (office name)
Patient name and number
Telephone (name)
Agency/Business
Call date
Verification statement
Identification Verification
Name (I C P N B)
Name (I C P N B)
Document type or number
Document type or number
Present
Present
Exempt
Exempt
Name (I C P N B)
Name (I C P N B)
Document type or number
Document type or number
Present
Present
Exempt
Exempt
Name (I C P N B)
Name (I C P N B)
Document type or number
Document type or number
Present
Present
Exempt
Exempt
Name (I C P N B)
Name (I C P N B)
Document type or number
Document type or number
Present
Present
Exempt
Exempt
Medicaid/OWF/SNAP verification
WIC personnel signature
Date
HEA 4460 (Revised 4/19)
This institution is an equal opportunity provider.