WIC applicants in Tennessee must be found to have a medical or nutritional risk, and the WIC assessment uses current measurements and periodic blood screening. This one-page referral lets a provider send those values with the patient's details: height or length, weight, hematocrit or hemoglobin with their dates, the estimated delivery date for a pregnant patient, primary language, and any nutrition or health concerns.
The health care provider's office completes the patient and provider sections, which the form marks to be completed by the health care provider, and the physician or a designee signs.
Download the current version from the source each time; forms change without notice.
TN WIC Referral Form
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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The signature line on PH-3151 reads physician's (or designee) signature, so a designee in the practice can sign. The provider section also asks for the office or clinic name, phone, fax and email, and the patient block is marked to be completed by the health care provider.
Fax or email a copy to the patient's local WIC office or local health department. The form directs providers to the Tennessee WIC web page for each office's contact information and has blanks at the top for the WIC office phone, fax and email.
The form says WIC serves pregnant, breastfeeding and postpartum women, infants, and children up to age 5. Applicants must be found to have a medical or nutritional risk, which WIC assesses using current measurements and periodic blood screening.