Health care providers and referring agencies use this one-page form to connect a patient to Indiana WIC, which serves pregnant and breastfeeding clients, postpartum clients, infants and children under 5. It captures the patient's name, birth date, contact details, primary language and comments. When WIC receives it, staff contact the client to schedule an appointment.
The provider's office or referring agency fills in the patient details and comments. The patient, parent or guardian signs the authorization letting the provider or agency release the information to Indiana WIC.
Download the current version from the source each time; forms change without notice.
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.
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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When WIC receives a referral form, staff contact the client to schedule an appointment. The primary language field and comments box help the local agency reach the family, and the signed authorization allows the provider or agency to release the information to WIC.
No. The form has no printed fields for measurements or bloodwork. It collects the client's name, birth date, address, phone, primary language and free-text comments. Formula requests travel separately on the Indiana WIC Medical Documentation Form.