North Carolina health care providers use this fillable form to share a patient's measurements, lab values and diagnoses with the local WIC program. WIC uses the provider's height or length, weight, hemoglobin and nutrition-related diagnoses when certifying the patient and assessing nutrition risk. It is separate from the NC WIC Medical Documentation form used for special formula.
The patient's health care provider or office staff complete the measurements, lab values and diagnoses and sign the form.
Download the current version from the source each time; forms change without notice.
WIC Program Exchange of Information
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It lets a health care provider share the measurements, lab values and diagnoses WIC needs, such as height or length, weight and hemoglobin, with the patient's local WIC clinic. That information supports the patient's WIC certification and nutrition assessment. Requests for special formula use the separate NC WIC Medical Documentation form.
NC DHHS offers an online NC WIC Families Referral Form on its health care provider resources page and asks providers to encourage patients to apply. The Exchange of Information form can then carry the patient's measurements and lab values to the local WIC clinic.