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Connecticut WIC 200-13 Certification/Medical Referral

Connecticut WIC uses this referral to certify a patient with health data the medical home already has: weight, length or height, BMI, hemoglobin or hematocrit, lead screening, immunizations and nutrition risks. The WIC nutritionist reviews it, enters the risks in the state WIC system and uses them for the assessment and food package.

Who completes it

The health care provider (MD, DO, PA, APRN or RN) enters health data, checks nutrition risks and signs with title, date and practice location. The parent or patient signs the page 2 release, and the WIC CPA completes the shaded area.

Submitting and payment

How to submit it
Give the form to the parent to bring to the WIC certification appointment or fax it to the local WIC clinic. Weight and length or height must be measured within 60 days of that appointment.

Good to know

  • Separate versions exist for infants and children and for women, both fillable. By signing, the provider verifies having seen and evaluated the patient, even when the form is used only for care coordination.
  • Hemoglobin or hematocrit timing follows the first infant test at 9 to 12 months, then 15 to 18 months, and at 2, 3 and 4 years. Abnormal results need a repeat within 6 months.
  • The release lets the named providers share health information with WIC and is valid for one year from signature. If the family declines, WIC takes measurements in its own office.
  • The form isn't required for certification, but Connecticut WIC calls it best practice to give families the form for their provider to verify conditions and support continuity of care.

Get the official form

Download the current version from the source each time; forms change without notice.

WIC Certification and Medical Referral Form

Official pagePDF

How this list is checked

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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Frequently asked questions

Which nutrition risks can a provider check on the CT WIC 200-13?

The infant and child version lists growth risks using WHO standards under age 2 and CDC charts from 2 to 5, such as underweight or short stature, plus anemia, elevated blood lead, food allergy, gastrointestinal disorders, prematurity, low birth weight, oral health conditions, fetal alcohol spectrum disorders and neonatal abstinence syndrome.

Who can sign the Connecticut WIC Certification/Medical Referral Form?

The guidelines name an MD, DO, PA, APRN or RN as the health care provider who signs. The signature verifies the clinician has seen and evaluated the patient, and the completed form must include the date and the address of the practice, clinic or office.