GEORGIA WIC PROGRAM POLICY AND PROCEDURES MANUAL CT Referral Data

Policy No. CT- 810.04 Effective Date: October 1, 2016

No. of Pages: 1

Revised: June 2018 Page 1 of 1

Policy Nutritional risk determination may be based on referral data for anthropometric and hematologic measurements furnished by a health care provider in lieu of measurements obtained at the clinic site. Referral data from the health care provider may be received in written or verbal format. If verbal data is used, the referral source and date the information was obtained must be documented in the medical record.

Purpose To increase clinic efficiency and customer access to WIC services.

Procedures

I. Local agencies must accept the referral data on the Georgia WIC Referral Form or on official letterhead/prescription pad from a private provider, provided that the entire minimum required referral data/information is included. II. Ensure all private provider referral forms contain, at a minimum, the following information: A. Applicant’s first and last name

B. Referral Agency/Medical Provider name

C. Medical Provider contact information

D. Medical/Hematological Data Date(s) when the information is included as part of the referral

III. Local agencies should make the authorized referral form available to area health care providers to facilitate entry into the Georgia WIC Program. Local agencies may not develop their own referral form.

Authority 7 CFR § 246.7 (e)

Definitions/Supporting Information (None)