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Florida WIC Medical Referral Form (DH 3075)

Florida health care providers use this referral to send a patient's measurements and bloodwork to WIC for the certification appointment. Shaded sections differ for pregnant women, breastfeeding and postpartum women, infants and children under 24 months, and children 2 to 5. The WIC nutritionist uses the information to determine eligibility, plan care and counsel the family.

Who completes it

The health professional taking the measurements, or a designee, completes the shaded section for the client's category, checks any health problems, signs, and adds the office address, phone and stamp. WIC staff fill in the certification appointment date.

Submitting and payment

How to submit it
Give the completed form to the client or parent to bring to the WIC certification appointment, or mail or fax it to the local WIC agency shown in the bottom left corner of the form.

Good to know

  • Height and weight must be taken no more than 60 days before the WIC appointment. Bloodwork for a pregnant woman can be any age if drawn during the current pregnancy.
  • Infants and toddlers need hemoglobin or hematocrit once between 6 and 12 months and once between 12 and 24 months. Children 2 to 5 need it yearly, or in 6 months if low.
  • Refer the client even if no health problem is checked. Options include food allergy, breastfeeding complications, lead of 3.5 mcg/dL or more, recent surgery or burns, and diet counseling.
  • All shaded areas must be completed for the form to be processed. The form asks parents to bring the child's shot record to the WIC office.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Referral Form

Official pagePDF

Fill it with Vero

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.

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How this list is checked

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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Frequently asked questions

How recent must measurements be on Florida's WIC Medical Referral Form?

Height and weight must be taken no more than 60 days before the client's WIC appointment, for every category. Bloodwork has no age limit for pregnant women as long as it was drawn during the current pregnancy, and for postpartum women it must be from after the most recent delivery.

Does the Florida WIC referral affect Healthy Start eligibility?

No. The form asks whether the client was screened and found eligible for Healthy Start, and the box is left blank if the client wasn't screened. The instructions state that Healthy Start eligibility does not affect a client's eligibility for WIC.

Who signs the Florida WIC Medical Referral Form?

The instructions call for the signature and title of the health professional who took the measurements, or that person's designee, along with the office address, phone number and an office or professional stamp. By signing, the professional refers the client to WIC for an eligibility determination.