Health care providers, social service programs and WIC staff use this one-page referral to connect a patient to Missouri WIC or other needed services. A physician's office can include current weight and length or height, birth measurements for infants, hemoglobin or hematocrit, lead results and reasons such as prematurity, poor growth or breastfeeding concerns.
The referring provider completes the patient details, measurements and reasons, then signs with printed name, address and phone. The patient, participant or guardian signs the acknowledgment at the bottom.
Download the current version from the source each time; forms change without notice.
WIC Referral Form
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The WIC-61 lets the referring provider ask WIC to waive the physical presence requirement because the participant is medically fragile or hospitalized, with a projected discharge date no more than one week away. The family acknowledges that WIC formula or food cannot be used while the child is still in the hospital.
No. The referral shares measurements and reasons for referral. Exempt formula, WIC-eligible nutritionals and food changes require the WIC-27 Medical Documentation form signed by a prescriptive authority, and Missouri WIC does not accept a regular prescription in its place.