Health care providers use this two-page New York WIC form, revised 2/18, to refer a woman, infant or child to WIC or to update health information. WIC nutritionists use the measurements, blood work and diagnoses to plan nutrition care and counseling. Each patient needs a separate form, and sections B, C and D must come from a health care provider.
The health care provider completes Section B (measurements and blood work for a woman, an infant under 24 months or a child 2 to 5), Section C (diagnoses or nutrition concerns) and Section D (name, signature, date or office stamp). The patient or parent signs the Section E release.
Download the current version from the source each time; forms change without notice.
Medical Referral Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
For children 2 to 5, the instructions treat hemoglobin below 11.1 or hematocrit below 33% as outside the normal range, which means retesting at 6-month intervals instead of yearly. Venous lead values and the date taken can be added when available.
Significant diagnoses, medical history and nutrition or health concerns, plus any specific nutrition counseling the provider wants WIC to give, for example for breastfeeding complications or food allergies. WIC staff may contact the provider's office for more detail before providing services.