New Hampshire WIC asks health care providers to document children's measurements and blood work on this one-page form so families can supply the information required for WIC participation. After a parent signs the release, the office records length or height, weight, hemoglobin or hematocrit and lead for up to three children, then sends the form to the local WIC agency.
The parent or guardian signs the authorization at the top, naming each child and date of birth. The provider's office records each child's measurement date and results, the provider's name and clinic, and the staff member completing the form.
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WIC Medical Documentation Form
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For each child, the measurement date, length or height, weight, hemoglobin or hematocrit, and lead level. The provider's name, medical office, contact details and the staff person completing the form go at the bottom. A parent or guardian signs the release at the top first.
To the local WIC agency serving the family's county, by email or fax. The form names Goodwin Community Health Center, Community Action Partnership, Southwestern Community Services, and Community Action Program Belknap-Merrimack Counties, each with the counties it covers.
No. It documents measurements, hemoglobin or hematocrit, and lead. New Hampshire WIC posts separate forms on its health care provider page to request standard formula or special formula and foods, and special or exempt formulas require a documented nutrition-related ICD-10 diagnosis.