Form DOH-132 "Wic Medical Referral Form for Infants and Children" - New York

What Is Form DOH-132?

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

Form Details:

  • Released on October 1, 2008;
  • The latest edition provided by the New York State 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 DOH-132 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

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Download Form DOH-132 "Wic Medical Referral Form for Infants and Children" - New York

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Date Mailed/
NEW YORK STATE DEPARTMENT OF HEALTH
For WIC 
Date Rec’d
Given
Use:
DIVISION OF NUTRITION
Appt Date
WIC ID #
WIC MEDICAL REFERRAL FORM FOR
INFANTS and CHILDREN
Child’s Last Name (Print):__________________________________________ Child’s First Name: ___________________________________ 
_
Parent/Caretaker’s Name:_________________________________________ Street: ________________________ Apt: ________________
_
_
□  
□     
City:_____________________________________ Zip:__________________ On WIC Before:   Yes 
_
  No 
     Sex:    M 
    F 
Phone: (            ) ________  ‐ _______ Child's DOB: ______/______/______ Language(s) Spoken: __________________________________
_
_
I authorize __________________________________________________(Health Care Provider) to release the information below to the WIC Program, and I authorize the WIC
Program to release information about my infant/child to this health care provider for the purposes of coordinating his/her health care. If I need to transfer to another WIC
Program, I authorize the release of this information to the transferring WIC Program.  All information is considered confidential.
YOUR SIGNATURE: _________________________________________
Health Care Provider: Please complete this section.  
 
 
BIRTH HISTORY:  
SGA
(<10th Weight for Gestational Age)
WEIGHT and HEIGHT must be less than 60 days old on the date of the
WIC appointment _____/_____/_____
Date Taken:
Birth Weight ______lb ______oz       OR         _______kg
Current Weight _____lb _____oz OR  _____kg   
_____/_____/_____
Current Height/Length _____in OR  ______cm      
_____/_____/_____
Birth Length ________in OR   ________cm   Weeks Gestation_________
Measurement Taken:       
 Standing          
 Recumbent (< 2 yrs)
HEMATOLOGY:
Date Taken:
Provide marker IMMUNIZATION dates or attach a copy of record.
Hgb __________gm/dL  OR   Hct_______    ______%      
First
Second
Third
Fourth
Fifth
 ____/____/____
Hep
Blood Lead 
__________ mcg/dL at one year of age      
 
   
 
   
____/____/____
B
DTP/D
Tap
Blood Lead __________ mcg/dL at two years of age      
____/____/____
MMR
SPECIFIC MEDICAL DIAGNOSIS OR NUTRITIONAL/HEALTH RISKS including ICD‐9 code
Provider's Name (Please Print):
Signature of Health Care Provider                                         
Title:
Medical Office/Clinic:
Street:
City:     
Zip:
Phone #:
Fax #:
 
 
Date:  ______/______/______
Send Completed Form To:
DOH‐132 (10/08)                                                               This institution is an equal opportunity provider.
Date Mailed/
NEW YORK STATE DEPARTMENT OF HEALTH
For WIC 
Date Rec’d
Given
Use:
DIVISION OF NUTRITION
Appt Date
WIC ID #
WIC MEDICAL REFERRAL FORM FOR
INFANTS and CHILDREN
Child’s Last Name (Print):__________________________________________ Child’s First Name: ___________________________________ 
_
Parent/Caretaker’s Name:_________________________________________ Street: ________________________ Apt: ________________
_
_
□  
□     
City:_____________________________________ Zip:__________________ On WIC Before:   Yes 
_
  No 
     Sex:    M 
    F 
Phone: (            ) ________  ‐ _______ Child's DOB: ______/______/______ Language(s) Spoken: __________________________________
_
_
I authorize __________________________________________________(Health Care Provider) to release the information below to the WIC Program, and I authorize the WIC
Program to release information about my infant/child to this health care provider for the purposes of coordinating his/her health care. If I need to transfer to another WIC
Program, I authorize the release of this information to the transferring WIC Program.  All information is considered confidential.
YOUR SIGNATURE: _________________________________________
Health Care Provider: Please complete this section.  
 
 
BIRTH HISTORY:  
SGA
(<10th Weight for Gestational Age)
WEIGHT and HEIGHT must be less than 60 days old on the date of the
WIC appointment _____/_____/_____
Date Taken:
Birth Weight ______lb ______oz       OR         _______kg
Current Weight _____lb _____oz OR  _____kg   
_____/_____/_____
Current Height/Length _____in OR  ______cm      
_____/_____/_____
Birth Length ________in OR   ________cm   Weeks Gestation_________
Measurement Taken:       
 Standing          
 Recumbent (< 2 yrs)
HEMATOLOGY:
Date Taken:
Provide marker IMMUNIZATION dates or attach a copy of record.
Hgb __________gm/dL  OR   Hct_______    ______%      
First
Second
Third
Fourth
Fifth
 ____/____/____
Hep
Blood Lead 
__________ mcg/dL at one year of age      
 
   
 
   
____/____/____
B
DTP/D
Tap
Blood Lead __________ mcg/dL at two years of age      
____/____/____
MMR
SPECIFIC MEDICAL DIAGNOSIS OR NUTRITIONAL/HEALTH RISKS including ICD‐9 code
Provider's Name (Please Print):
Signature of Health Care Provider                                         
Title:
Medical Office/Clinic:
Street:
City:     
Zip:
Phone #:
Fax #:
 
 
Date:  ______/______/______
Send Completed Form To:
DOH‐132 (10/08)                                                               This institution is an equal opportunity provider.
Date Mailed/
NEW YORK STATE DEPARTMENT OF HEALTH          
For WIC 
Date Rec’d
Given
Use:
DIVISION OF NUTRITION
Appt Date
WIC ID #
WIC MEDICAL REFERRAL FORM FOR WOMEN  
Last Name (Print):_____________________________________
First Name: _______________________________________________
Street:____________________________________Apt:_______
City: _____________________________
Zip:_________________
□  
Phone: (            ) ________  ‐ ________
Date of Birth: ______/______/______
On WIC Before:   Yes 
  No 
Maiden Name:_____________________________________________
Language(s) Spoken: __________________________________
I authorize __________________________________________________(Health Care Provider) to release the information below to the WIC Program, and I authorize
the WIC Program to release information about me to this health care provider for the purposes of coordinating my health care. If I need to transfer to another WIC
Program, I authorize the release of this information to the transferring WIC Program.  All information is considered confidential.
YOUR SIGNATURE: ___________________________________________
Health Care Provider: Please complete this section.  
PRENATAL OR POSTPARTUM:
WEIGHT and HEIGHT must be less than 60 days old on the date
Gravida _______    Para_______        Multi Fetal____________
of the WIC appointment: _____/_____/_____
Date:
Pregravid Weight __________pounds
Date Taken:
Current Weight__________pounds
_____/_____/_____
EDD _____/_____/_____
_____/_____/_____
Prenatal Care Began _____/_____/_____
Current Height___________ inches
th
 Fetal Weight <10
 Percentile for Gestational Age
HEMATOLOGY:
BREASTFEEDING/POSTPARTUM:  Most Recent Pregnancy
Date Taken:
Hgb ______gm/dL  OR   Hct______%          
_____/_____/_____
Date of Delivery/(Termination, if any)    _____/_____/_____
Blood Lead __________mcg/dL 
_____/_____/_____
(Optional)
Total Weight Gained______pounds     Weeks Gestation______
•Bloodwork must be taken during current pregnancy.
•Bloodwork must be taken after delivery for Breastfeeding/ Postpartum 
Current Infant’s Birth Weight ______lb ______oz  OR  ______kg
Women.
SPECIFIC MEDICAL DIAGNOSIS OR NUTRITIONAL/HEALTH RISKS including ICD‐9 code
Provider's Name (Please Print):
Signature of Health Care Provider                                         
Title:
Medical Office/Clinic:
Street:
City:    
Zip:
Phone #:
Fax #:
 
 
Date:
 ______/______/______
Send Completed Form To:
DOH‐799 (10/08)                                                          This institution is an equal opportunity provider.
NEW YORK STATE DEPARTMENT OF HEALTH
DIVISION OF NUTRITION
MEDICAL DOCUMENTATION FOR WIC FORMULA AND APPROVED WIC FOODS FOR
DRAFT
INFANTS, CHILDREN AND WOMEN
Patient’s Name _____________________________________________________ Birth Date (MM/DD/YY) ____________________________
Birth Date: (MM/DD/YY) ______________________________________________
Parent/Caretaker's First and Last Name________________________________________________________________________________________
I authorize __________________________________________________ (Health Care Provider) to release the information below to the WIC Program, and I authorize the WIC
Program to release information about me to this health care provider for the purposes of coordinating my health care. If I need to transfer to another WIC Program, I
authorize the release of this information to the transferring WIC Program. All information is considered confidential.
YOUR SIGNATURE: ___________________________________________________
Prescription is subject to WIC approval and provision based on Program policy and procedure.
Qualifying medical condition(s) including ICD-9 code: Justifies the prescription of requested formula/medical food
_____________________________________________________________________________________ ICD-9 Code________________________
WIC formula/medical food requested: _______________________________________________________________________________________
Prescribed amount per day: _______ oz/day
Special Instructions/Comments:____________________________________________________
Length of use: ______________________________________ (Prescription renewal required periodically)
The patient will receive the supplemental foods, appropriate to their WIC participant category, listed below in addition to the WIC
formula/medical food. Please indicate any supplemental foods or restrictions that would be contraindicated with the patient's medical
diagnosis.
WIC Participant
WIC Supplemental Foods
Do Not
Restrictions/Comments
Category
Available
Give
Infants (6-12 months)
Infant Cereal
Infant Food Vegetables/Fruits
Children and Women
Milk
Cheese
Cereal
Juice
Eggs
Vegetables/Fruits
Whole Wheat Bread
Beans
Peanut Butter
Canned Fish *
* "Fully Breastfeeding Women" is the only WIC participant category eligible to receive canned fish.
Provider's Name (Please Print):
Signature of Health Care Provider
Title:
Medical Office/Clinic:
Street:
City:
Zip:
Phone #:
Fax #:
Date:
/
/
This institution is an equal opportunity provider.
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