This one-page form lets a New Mexico clinician pass a patient's height, weight, hemoglobin or hematocrit and nutrition concerns to WIC, so the program can document the medical or nutritional risk needed for enrollment. It has separate blocks for pregnant women, breastfeeding and postpartum women, infants and children under 24 months, and children 2 to 5. Sending it helps WIC avoid repeating bloodwork and measurements.
The health care provider completes the patient information and the block that matches the patient, checks any conditions, and signs or stamps it (MD, DO, PA or CNP) with an NPI.
Download the current version from the source each time; forms change without notice.
New Mexico WIC Program Medical Referral Form
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No. New Mexico WIC's health care provider page says the referral is not mandatory, but it helps WIC document the risk factor needed for enrollment, avoid repeating bloodwork and measurements, and give better counseling and referrals. The form asks providers to refer patients even when none of the condition boxes apply.
Height and weight for women and for children 2 to 5 must be no older than 60 days. For infants and children under 24 months, weight and length must be within 30 days and hemoglobin or hematocrit within 60 days. Pregnant women need a value from the current pregnancy.
A health care provider signs or stamps it and marks MD, DO, PA or CNP, then adds the date, printed name, NPI, phone and fax. The provider block is labeled required, as is the patient information block at the top of the form.