Tip for State-specific

Pregnant women, postpartum/breastfeeding mothers, infants, and children up to age 5 are eligible

Tip for State-specific

You can apply during pregnancy — don't wait until the baby is born

Tip for State-specific

WIC income limits are typically 185% of the federal poverty level

Maternal & PediatriceasyDoctor signature required

WIC Medical Documentation / Nutrition Risk Form

State-specific · State WIC agencies

Medical documentation of nutrition risk factors qualifying an individual for WIC, such as anemia, underweight, or high-risk pregnancy.

Form Details

Total fields: 25
Auto-fillable: 18 (72%)
Time without BeneFill: 15 minutes
Time with BeneFill: 5 minutes
Time saved: 10 minutes
Filled by: doctor
Frequency: annual
State-specific: Yes — form may vary by state

Fill this form with BeneFill

Auto-fill 72% of fields from your profile. Save 10 minutes. Download a real PDF.

18 of 25 fields72% auto-filled

Start Filling Upload Your Copy Instead

Where to Submit This Form

🏢

Submit at your local WIC clinic

https://www.fns.usda.gov/wic/wic-how-apply

Must be submitted during a WIC certification or recertification appointment.

📬

Mail to your local WIC office

Contact your state or local WIC agency for the mailing address.

Filing Deadline

Must be completed before or at the WIC certification appointment. Medical documentation is typically valid for the length of the certification period (6-12 months).

Required Attachments

📎 Completed medical referral form signed by a healthcare provider (physician, PA, NP, or nurse)
📎 Height/weight and blood work results (hemoglobin or hematocrit)
📎 Proof of identity (birth certificate, driver's license)
📎 Proof of income or participation in Medicaid/SNAP/TANF
📎 Proof of residency in the state

Processing Time

Same-day determination at the WIC clinic appointment if all documentation is complete.

What Happens Next

You will receive a WIC EBT card or vouchers at the appointment. A food package will be tailored to your nutritional needs.

Tips for This Form

✓ Pregnant women, postpartum/breastfeeding mothers, infants, and children up to age 5 are eligible
✓ You can apply during pregnancy — don't wait until the baby is born
✓ WIC income limits are typically 185% of the federal poverty level
✓ If you receive Medicaid, SNAP, or TANF, you are automatically income-eligible for WIC

More Maternal & Pediatric Forms

WIC Application

State-specific · USDA Food and Nutrition Service (state-administered)

Application for WIC nutrition assistance providing education, breastfeeding support, and benefits for healthy foods. Requires proof of identity, address, income (or Medicaid/SNAP/TANF participation), and a health screening.

CHIP Application

State-specific / Healthcare.gov · State CHIP agencies

Application for Children's Health Insurance Program for families with income too high for Medicaid but too low for private coverage. Uses MAGI-based financial eligibility. Children must be uninsured.

School Entrance Health Form

State-specific (e.g., VA MCH213G) · State Departments of Health/Education

Required for school entry. Includes immunization records, health history, physical examination, and developmental screening. Must be completed no earlier than one year before school entry.

Immunization Record / Certificate of Immunization

State-specific · State Departments of Health

Official record of required childhood vaccinations for school enrollment. Exemption forms (medical, religious, philosophical) vary by state.

Medication Administration Authorization (School)

District-specific · School districts

Authorization for school nurse or designee to administer prescribed medication during school hours.

Section 504 Plan (Medical)

District-specific · School districts

Accommodation plan for students with health conditions (diabetes, allergies, asthma, ADHD) that impact school participation. Includes a medical management plan and emergency action plan.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State WIC agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.