Revised 1-2018 Connecticut WIC Program Manual

WIC 200-13 SECTION: Certification

SUBJECT: Completion of WIC Certification/Medical Referral Form in CT-WIC

Federal Regulations: §246.7 (i) and (j) See also WIC 200-12 WIC Nutrition Assessment Screens and Guidance; 200-22 Disposition of Certification Files POLICY The policy provides guidance on the requirements for the WIC Certification Form / Medical Referral Form. This is a two-sided form; the front contains the participant health data and risk factors, and the back of the form contains the applicant or participant authorization information. BACKGROUND Previously, all WIC applicants/participants were required to have a completed WIC Certification/Medical Referral Form (See also WIC 200-12 WIC Nutrition Assessment Screens and Guidance) in the paper file. It required the Competent Professional Authority’s (CPA) signature or countersignature on the medical/nutritional assessment form and another WIC local agency staff member’s signature to verify the income eligibility determination and documentation. For more details on the completion of the WIC Certification/ Medical Referral Form, please refer to the Guidelines for Use, which is the last page of the form(s). Completion of the Certification/Medical Referral Section: If the WIC Certification/ Medical Referral Form is completed by a CPA not on staff of the local agency i.e. physician, nurse practitioner, and provided in hardcopy to the WIC Program upon certification, the form must be reviewed, countersigned by a WIC CPA on staff at the local agency and scanned into the participant’s CT-WIC record. WIC Staff signatures on the WIC Certification/Medical Referral Form are to be handwritten, legible and comprise at a minimum, the first initial and last name. If the Crib Card in used in lieu of the of the Certification/Medical Referral form, the Crib Card must be scanned into the participant’s CT-WIC record. However, a counter signature is not required. WIC applicants or participants that present for an appointment without a hardcopy WIC Certification/Medical Referral Form DO NOT need to have a paper form completed and scanned into CT-WIC. The completion of the Nutrition Risk and Nutrition Education Screens in CT-WIC serves as the signature of the WIC CPA. Completion of the Applicant/Participant Authorization Section:

All applicants/participants must complete this Form. This Form must be completed as hardcopy and scanned into the CT-WIC record because it requires WIC staff to record the health care provider and/or other organizations on the form. This information doesn’t auto-populate in the Form in CT- WIC. This section can be completed:

Revised 1-2018 • Prior to the next certification appointment (i.e. in preparation for the applicant/participant taking the form to a prenatal, post-partum or well-child exam) or

• When the participant brings a completed Certification/Medical Referral Form to a WIC appointment

Staff can inform applicants and participants about the purpose of this form:

By signing this you acknowledge you understand how WIC uses health information to determine WIC eligibility. You are also agreeing to give permission to share your health information on the certification form with WIC, and in order to coordinate your care WIC staff may talk to your health care provider or other listed organizations about any health, medical or behavioral concerns and/or information on this form.

If over the course of the certification period, any changes or updates are required to the health care provider or organizations listed, staff can indicate changes in the spaces provided. At a minimum, this form should list the applicant/participants primary health care provider or the practice. In some cases, WIC participants’ may receive other services i.e. Early Intervention, Nurturing Families, Head Start or Obesity Clinic, that may be prudent to communicate with to coordinate care. Any changes should be updated on a new Form and scanned into the CT-WIC file.

An applicant or a participant can decline to allow the HCP to share her or her infant/child’s information with WIC. If this occurs, WIC staff must take necessary anthropometric measurements in the office to complete the WIC certification process.

As the Form indicates, the participant can cancel the permission at any time; there are instructions for the participant on the form to cancel the permission in this section. WIC staff should review this information with the applicant/participant. There is a space on the form for WIC staff to record when the permission was cancelled. In the case of a participant cancelling permission, print out a copy of the scanned Form in CT-WIC and indicate for which provider or organization that permission was canceled, and then re-scan the Form into CT-WIC.