Michigan WIC asks health care providers for recent measurements and lab values on MDHHS-5916 so WIC staff can complete a health and nutrition assessment, especially when services are delivered remotely. Based on the most recent visit, the provider records length or height, weight, head circumference for children under 24 months, hemoglobin or hematocrit, lead testing, and birth data for infants, for up to two clients.
The medical provider's office enters the measurements, lab values and dates taken, plus the doctor or clinic name and phone. WIC lists it among forms for providers authorized to write prescriptions; the WIC agency's name and contact details show where it goes.
Download the current version from the source each time; forms change without notice.
WIC Anthropometric and Laboratory Information Request
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.
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An August 2023 MDHHS memo explains that WIC returned to in-person services while keeping remote services where needed through September 2026. Remote services still require anthropometric and hemoglobin or hematocrit data, and sharing it from the provider's records helps WIC complete the assessment.
To the client's local WIC clinic, or back to the client to bring to WIC. If the values are already visible in the client's patient portal, the client can share them with WIC directly and the form does not need to duplicate them.
Yes. The form has space for two clients, each with full name, date of birth, parent or guardian, measurements, hemoglobin or hematocrit, lead test and, for infants, birth data. The current version is dated 3-21.