Pennsylvania WIC posts this referral on pawic.com, where it is listed as the Women's Referral Form, for providers sending a pregnant or postpartum patient to WIC. The provider records prenatal or postpartum measurements, lab values such as hemoglobin, and nutrition-risk information. WIC uses that data when it certifies the patient for benefits.
A licensed health care provider with prescriptive authority (MD, DO, NP or PA) completes the measurements, labs and referral information for the patient.
Download the current version from the source each time; forms change without notice.
PA WIC Women's Health Referral Form
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It is Pennsylvania WIC's referral for pregnant and postpartum women. The provider fills in prenatal or postpartum measurements, lab values and nutrition-risk information, and WIC uses that data when certifying the patient. It is posted on pawic.com, where it is listed as the Women's Referral Form.
A licensed health care provider with prescriptive authority, such as a physician (MD or DO), nurse practitioner or physician assistant, completes the measurements, labs and referral details. The patient then brings it to WIC, or the office faxes it to the local clinic.
Fax it to the patient's local WIC clinic, or hand it to the patient to bring to the WIC appointment. The version dated June 25, 2021 is the one currently posted for health care providers on the Pennsylvania WIC website.