Minnesota health care providers use this online form to refer patients to WIC and to send height, weight and hemoglobin measurements to the patient's WIC clinic. It can also send updated medical data for families already on WIC. When a provider shares measurements, WIC can usually serve the family remotely instead of in person.
The health care provider or clinic staff complete the online form for the patient. There is no paper version to sign and fax.
Download the current version from the source each time; forms change without notice.
Minnesota WIC Referral Form
This form is completed online with Minnesota Department of Health, WIC Program, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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Yes. MDH says the referral form may also be used to provide medical data to the WIC Program for current participants, not only to refer new families. Sending height, weight and hemoglobin this way usually lets the family be served remotely rather than in person.
No. Formula is requested on the Minnesota WIC Medical Formula Request Form (Exhibit 7-D), which needs a qualifying diagnosis and is faxed or returned to the WIC office. The online referral only connects the family to WIC and shares measurements.
Child and Teen Checkups require hemoglobin or hematocrit at one visit between 9 and 15 months and once between 11 and 20 years for menstruating youth, while WIC screens at 9 and 18 months and yearly. MDH notes a C&TC hemoglobin outside 9 to 15 months can be billed when medically necessary.