Article Structure
The DH 3075 form is an essential document for the Florida WIC Program, intended to help ensure that pregnant women, infants, and young children receive vital nutrition assistance. This medical referral form collects necessary information regarding the health status of the client, including details such as height, weight, and specific medical conditions that might affect nutritional needs. Key sections of the form address whether the client is eligible for the Healthy Start program, a vital resources for expecting mothers and families. Additionally, it guides health professionals in recording important lab values like hemoglobin or hematocrit measurements, which are crucial for assessing the overall health of pregnant women and children. Referrals to the Women, Infants, and Children (WIC) program are supported through this form, encouraging healthcare providers to recommend their clients, even if no health issues are identified. To make the process smooth, shaded areas on the form must be completed, and the instructions for filling it out are conveniently located on the reverse side. By facilitating access to proper nutritional resources, the DH 3075 form plays a significant role in supporting the health and well-being of Florida families.
Dh 3075 Example
Florida WIC Program Medical Referral Form
Shaded areas must be completed. See instructions for completing this form on the reverse side.
Is this client eligible for Healthy Start? ❑ Yes ❑ No |
For WIC Office Use Only: |
|
|
Date of WIC Certification Appointment ______________ |
|
|
|
|
Client’s Name __________________________________ |
Birth Date ________________ |
Sex M F |
Address _______________________________________ |
Phone Number (______) |
|
City ___________________________ Zip Code _______ |
Social Security # |
|
Parent’s/Guardian’s Name __________________________________ (for infants and children only)
❑ For Pregnant Women
Height ______ inches |
Weight ______ lb |
Date Taken ____________ (no older than 60 days) |
Hemoglobin _________ OR Hematocrit _________ |
Date Taken ____________ (must be during current pregnancy) |
|
Expected Date of Delivery __________ Date of First Prenatal Visit __________ Prepregnancy Weight _________
❑For Breastfeeding and Postpartum
Height ______ inches |
Weight ______ lb |
Date Taken ____________(no older than 60 days) |
Hemoglobin _________ OR Hematocrit _________ |
Date Taken ____________ (must be in postpartum period) |
|
Date of Delivery __________ |
Date of First Prenatal Visit __________ Weight at Last Prenatal Visit _________ |
|
❑For Infants and Children less than 24 months of age
Birth Weight ______ lb ______ oz |
Birth Length _________ inches |
|
Current Height ______ inches |
Current Weight ______ lb |
Date Taken ____________ (no older than 60 days) |
Hemoglobin _________ OR Hematocrit _________ Date Taken ____________ (required once between 6 to 12 months
AND once between 12 to 24 months)
❑For Children 2 to 5 years of age
Height ______ inches |
Weight ______ lb |
Date Taken ____________ (no older than 60 days) |
Hemoglobin _________ OR Hematocrit _________ |
Date Taken ____________ (once a year unless value < 11.1 Hgb or |
|
|
|
< 33% Hct, then required in 6 months) |
✓Check all that apply. Please refer your client to WIC, even if nothing is checked below. This information
assists the WIC nutritionist in determining eligibility, developing a nutrition care plan, and providing nutrition counseling. WIC staff may need to contact you or your staff to obtain more detailed medical information prior to providing WIC services.
❑Medical condition (specify)
____________________________________
❑High venous lead level (10 μg/dl or more)
Lead level _______ Date Taken ____________
❑Recent major surgery, trauma, burns (specify)
____________________________________
❑Food allergy (specify) ________________________
❑Current or potential breastfeeding complications (specify) __________________________________
❑Other (specify) _____________________________
❑Nutrition Counseling Requested – specify diet prescription/order ___________________________________
WIC Local Agency Address:
I refer this client for WIC eligibility determination:
Signature/Title of Health Professional _____________________________
Date _________ PLEASE PLACE OFFICE STAMP BELOW:
Address:
Phone Number:
***Parent or Guardian: Please bring a copy of your baby’s/child’s shot record to the WIC ofice.***
DH 3075, 8/09 Stock Number:
Instructions for Completing the Florida WIC Program Medical Referral Form
All shaded areas must be completed in order for the form to be processed.
1.Check (✓) YES if the client has been screened and is eligible for Healthy Start. Check (✓) NO if the client is not eligible for Healthy Start. Leave blank if the client has not been screened. Note: Eligibility for Healthy Start does not affect a client’s eligibility for WIC.
2.Complete the client’s name and birth date.
3.Optional Information: the client’s sex, mailing address, phone number, city, zip code, social security number, and the parent’s or guardian’s name for infants and children.
4.Complete the appropriate shaded section for the client.
Pregnant Women: Complete the height and weight measurements and the date they were taken. These measurements are to be taken no more than 60 days before the client’s WIC appointment. (The WIC appointment may be recorded at the top of the form.) Complete the hemoglobin or hematocrit value and the date the value was taken. There is no limit on how old the bloodwork data can be, as long as the measurement was taken during the current pregnancy. Complete the expected date of delivery, the date of the client’s first prenatal visit, and the prepregnancy weight.
Breastfeeding Women (eligible up to one year after delivery) and Postpartum
Infants and Children less than 24 months of age: Complete the infant’s birth weight and birth length. Complete the current height and weight measurements and the date they were taken. These measurements are to be taken no more than 60 days before the client’s WIC appointment. (The WIC appointment may be recorded at the top of the form.) Complete the hemoglobin or hematocrit value and the date the value was taken. A bloodwork value is required once during infancy between 6 to 12 months of age (preferably between 9 to 12 months of age) and once between 1 to 2 years of age (preferably 6 months from the infant bloodwork value).
Children 2 to 5 years of age: Complete the current height and weight measurements and the date they were taken. These measurements are to be taken no more than 60 days before the client’s WIC appointment. (The WIC appointment may be recorded at the top of the form.) Complete the hemoglobin or hematocrit value and the date the value was taken. A bloodwork value is required once a year unless the value is abnormal
(< 11.1 hemoglobin or < 33% hematocrit), then a bloodwork value is required in 6 months.
5.Check (✓) any health problem that you have identified. Even if you have not identified a health problem, refer the client to the WIC program.
6.If you would like a nutritionist to counsel your client on a specific diet, check the box and specify the diet prescription or diet order requested.
7.If possible, please provide a copy of the immunization record for infant and child clients.
8.Complete the shaded area at the bottom of the form with the signature of the health professional taking the measurement or his/her designee and the office address and phone number. Stamp the form with the office stamp or the health professional’s stamp.
9.Give this completed form to the client or parent/guardian to bring to the WIC certification appointment or mail/fax the form to the local WIC agency address shown in the bottom left corner of the form.
Form Characteristics
| Fact Name | Description |
|---|---|
| Form Title | Florida WIC Program Medical Referral Form |
| Eligibility Screening | Clients must be screened to determine eligibility for the Healthy Start program, indicated by a check in the appropriate box. |
| Client Information | Essential client details such as name, birth date, and address need to be filled in the specified areas of the form. |
| Height and Weight Measurements | Height and weight must be recorded no more than 60 days before the WIC appointment. |
| Hemoglobin/Hematocrit Requirement | Hemoglobin or hematocrit levels must be documented, with specific requirements based on the age and status of the client. |
| Client Referral | Regardless of health conditions, it’s important to refer the client to the WIC program for assistance. |
| Office Stamp Requirement | A health professional’s signature and office stamp are required at the bottom of the form to validate it. |
| Document Version | This version of the DH 3075 form was released in August 2009 and replaces the earlier December 2003 edition. |
Guidelines on Utilizing Dh 3075
Filling out the DH 3075 form is an important step in ensuring clients receive the appropriate services from the Florida WIC Program. Following these steps will help streamline the process and ensure all necessary information is provided accurately.
- Start by checking the box for Healthy Start. If the client is eligible, mark "Yes." If not, mark "No." Leave blank if they haven't been screened.
- Complete the client's name and birth date.
- Fill in optional details such as the client's sex, mailing address, phone number, city, zip code, and social security number. If the client is an infant or child, include the parent's or guardian's name.
- Choose the right section based on the client type (Pregnant Women, Breastfeeding Women, Infants and Children, or Children 2 to 5 years). Complete the height, weight, and the date taken for these measurements, ensuring they are taken within 60 days of the WIC appointment.
- For pregnant women, record the hemoglobin or hematocrit value and the date taken. Make sure this date is during the current pregnancy. Also, provide the expected date of delivery, date of first prenatal visit, and prepregnancy weight.
- For breastfeeding and postpartum women, document the same information as for pregnant women, ensuring the data is from the appropriate time period. Include the date of delivery and the weight at the last prenatal visit.
- For infants, enter the birth weight, birth length, and current measurements (height and weight) along with the respective date taken. Bloodwork is required at ages 6 to 12 months and again from 12 to 24 months.
- For children aged 2 to 5, provide their height and weight along with the date taken. Bloodwork, if applicable, should be included.
- Identify any health issues by checking the relevant boxes. Even if no issues are found, make sure to refer the client to WIC.
- If specific nutrition counseling is needed, check the appropriate box and provide details of the diet prescription or order requested.
- If available, include a copy of the immunization record for infant and child clients.
- At the bottom, obtain the signature of the health professional who completed the form along with the office address and phone number. Remember to place the office stamp here.
- Finally, give the completed form to the client or their parent/guardian, or send it via mail or fax to the local WIC agency.
What You Should Know About This Form
-
What is the purpose of the DH 3075 form?
The DH 3075 form is the Florida WIC Program Medical Referral Form. It is used to determine eligibility for the Women, Infants, and Children (WIC) program. The form collects important health information about the client, which helps WIC nutritionists create tailored nutrition care plans. Proper completion ensures that clients receive the appropriate services.
-
Who needs to fill out the DH 3075 form?
The form must be completed by a qualified health professional who has evaluated the client. This could include doctors, nurses, or other healthcare providers. They will input information related to the client’s health status, nutritional needs, and other relevant factors. It's essential for ensuring an accurate assessment of eligibility for services.
-
What information is required on the form?
The DH 3075 form requires several key pieces of information, including the client’s name, date of birth, measurements (like height and weight), and health data such as hemoglobin or hematocrit levels. Specific sections need to be filled out based on whether the client is a pregnant woman, breastfeeding woman, postpartum woman, infant, or child. Every shaded area must be fully completed for the form to be processed.
-
What happens if the shaded areas are not filled out?
Incompleteness in the shaded areas may lead to the form being rejected or delayed in processing. Therefore, it is crucial that all required sections are filled out accurately and completely. This ensures swift action on the client’s eligibility and makes sure they receive the nutrition support they need.
-
What should a parent or guardian bring for the WIC appointment?
Parents or guardians should bring a copy of their baby’s or child’s immunization record to the WIC appointment. This documentation can assist WIC staff in getting a comprehensive view of the child's health and nutrition status, allowing for better care and resources.
-
How should the completed form be submitted?
The finalized DH 3075 form can be submitted in a couple of ways. It can be given directly to the client or their parent/guardian, who then brings it to the WIC certification appointment. Alternatively, the form can be mailed or faxed to the local WIC agency’s address as indicated on the form. This flexibility aids in streamlining the process for all parties involved.
Common mistakes
Filling out the DH 3075 form for the Florida WIC Program can be a straightforward process, but many make simple mistakes that can delay eligibility. One common mistake is neglecting to complete all the shaded areas, which are essential for the form to be processed. Every shaded box should be filled out accurately, as leaving them blank can result in an automatic rejection of the form.
Another frequent error involves incorrect measurements or outdated data. For instance, the height and weight for pregnant women, infants, and children must be taken no more than 60 days before the appointment. It’s equally important to ensure that hemoglobin or hematocrit results are current and relevant to the specified group. If these measurements are old or missing, it could lead to complications in processing the application.
People often mistakenly check the wrong eligibility questions. It is critical to answer whether the client is eligible for Healthy Start accurately. If this section is filled out incorrectly, it might confuse WIC staff and impact the client’s ability to receive services. Always double-check these answers to ensure they reflect the client's actual situation.
Additionally, there’s a tendency to overlook the optional information, such as the social security number or contact details. While this information may not seem crucial, it can assist in more efficient communication between the client and WIC representatives. Providing complete information helps in smooth processing and avoids unnecessary follow-up requests.
Lastly, some individuals forget to sign and date the form. A signature from a qualified health professional is necessary for the form to be valid. Failure to provide a signature could leave the whole document incomplete, delaying the process and potentially causing the client to miss their WIC appointment.
Documents used along the form
The DH 3075 form is a critical document used within the Florida WIC program to refer clients for eligibility determination. When submitting this form, there are several other important documents that may accompany it to ensure comprehensive data and facilitate the referral process. Below is a list of these documents, each described briefly.
- WIC Eligibility Worksheet: This document helps to gather preliminary information regarding a client's eligibility status based on income and household size, serving as a supplementary tool for the WIC staff.
- Health Assessment Form: Typically filled out by healthcare providers, this form gives insights into a client's medical history, health status, and any specific needs that may affect their eligibility and care.
- Immunization Record: Clients are often encouraged to provide a copy of this record. It helps WIC offices confirm current vaccinations and aligns with health guidelines for infants and children.
- Nutrition Counseling Consent Form: This form is signed by clients or guardians to authorize nutrition counseling, ensuring that clients receive guidance tailored to their specific dietary needs.
- Referral Letter from Healthcare Provider: A letter recommending the client for WIC services, typically detailing the client's health concerns and reasons for referral, can also be provided.
- Proof of Income Documentation: This may include pay stubs, tax returns, or other financial documents needed to verify household income for determining eligibility.
- Child Health Assessment Form: Used specifically for children, this document records growth measurements and health metrics, aiding in identifying the child's nutritional needs.
- Food Frequency Questionnaire: Clients may fill out this questionnaire to provide information about their dietary habits, which helps in creating a suitable nutrition plan.
- Application for Supplemental Nutrition Assistance Program (SNAP): In some cases, clients may submit this application alongside the DH 3075, especially if they are seeking integrated support services.
- Authorization for Release of Information: This form allows healthcare professionals to share necessary client information with WIC staff, streamlining communication and service delivery.
These accompanying documents enhance the referral process, ensuring that both WIC staff and clients understand eligibility requirements and available services. Their careful preparation can lead to a smoother onboarding process for clients seeking assistance.
Similar forms
- Florida Healthy Start Screening Form: Like the DH 3075, this document is utilized to assess eligibility for wellness and nutrition programs. Both forms require similar demographic information and health data such as medical conditions and pregnancy status, facilitating comprehensive support for maternal and child health.
- WIC Application Form: This form serves as a formal application for the Women, Infants, and Children program, focusing on eligibility determination. It parallels the DH 3075 by collecting essential information about the applicant’s health and nutritional needs, streamlining the process of accessing benefits.
- Medicaid Application Form: Much like the DH 3075, this application seeks to determine eligibility for assistance. Both forms require detailed personal and medical information to evaluate a participant’s needs, ensuring timely access to necessary resources.
- Food Assistance Program Application: Similar in purpose, this application aims to provide nutritional support. Like the DH 3075, it includes questions about household income, size, and medical conditions that could affect eligibility for food-related assistance programs.
- Child Health Check-Up Assessment Form: This document is critical for assessing children's health and wellness, much like the DH 3075 for WIC. Both forms gather data on growth parameters and health conditions to determine necessary interventions and services.
- Community Health Assessment Form: This form aims to collect data regarding overall community health, resembling the DH 3075. Both documents emphasize the importance of identifying medical conditions and nutritional needs, playing a vital role in community health planning and resource allocation.
Dos and Don'ts
When filling out the DH 3075 form for the Florida WIC Program, it’s essential to follow specific guidelines to ensure your submission is processed correctly. Below are some dos and don’ts to keep in mind:
- Do complete all shaded areas on the form as these are required for processing.
- Do check the eligibility for Healthy Start and mark “Yes” or “No” appropriately.
- Do provide accurate information regarding the client’s personal details, including name, birth date, and contact information.
- Do ensure that any height and weight measurements are current and taken no more than 60 days before the WIC appointment.
- Do use the correct dates for any medical values, ensuring they correspond to the proper time frame.
- Don't leave blank spaces in required shaded areas; this can delay processing.
- Don't submit old medical records that do not meet the specified time requirements.
- Don't skip checking any health issues even if there are none; referring clients to WIC is important.
- Don't forget to sign the form and include your contact information where indicated.
By following these guidelines, you can facilitate a smooth process for the client and ensure that they receive the assistance they need through the WIC program.
Misconceptions
Misconception 1: The DH 3075 form is only for pregnant women.
This form serves not just pregnant women, but also breastfeeding mothers, postpartum women, infants, and children under 5 years old. Its purpose is to assess eligibility for the WIC program across various groups.
Misconception 2: Completing the form is optional for referrals.
It is essential to complete the shaded areas of the DH 3075 form for it to be processed. Incomplete forms can delay or prevent access to WIC services.
Misconception 3: The measures taken don't need to be recent.
Measurements like height and weight must be taken no more than 60 days before the client's WIC appointment. Recent data helps ensure accurate eligibility assessments.
Misconception 4: If a client is screened for Healthy Start, it automatically qualifies them for WIC.
Eligibility for Healthy Start does not affect eligibility for WIC. They are separate programs, and clients must be evaluated for each one independently.
Misconception 5: Bloodwork results have no time restrictions.
Bloodwork for hemoglobin or hematocrit values must be current, but it should also be taken within specific time frames based on the client's age and situation. For example, infants need it between 6 to 24 months, and it should be recent.
Misconception 6: There's no need to provide additional information about medical conditions.
It is encouraged to provide as much detailed information about medical conditions as possible. This assists WIC nutritionists in developing appropriate care plans and nutrition counseling.
Misconception 7: The DH 3075 form can be processed without a health professional’s signature.
A signature from a health professional is crucial. This validates the information provided and ensures authenticity for the client’s referral.
Misconception 8: Copies of immunization records are not necessary.
Parents or guardians are encouraged to bring a copy of their baby’s or child’s shot record to the WIC appointment. This information can be important for eligibility and health assessments.
Misconception 9: Certain sections of the form can be left blank without consequences.
While some information is optional, critical areas must be filled out to avoid delays in processing. Any unfilled shaded areas can hinder eligibility determination.
Misconception 10: The DH 3075 form is only relevant in Florida.
Although this form pertains to the Florida WIC program, similar forms exist in other states. Always check local resources for specific forms and requirements in different locations.
Key takeaways
Key Takeaways about the DH 3075 Form:
- Complete all shaded areas to ensure the form is processed correctly.
- Include client eligibility for Healthy Start, but note that it does not affect WIC eligibility.
- Provide accurate measurements for height and weight taken within 60 days of the WIC appointment for pregnant women, breastfeeding women, and children.
- Refer the client to WIC even if no health problems are identified, as this assists in eligibility determination and nutrition counseling.
Browse Other Templates
Cdph 612 - The CDHP 609 form is used by healthcare facilities in California to request specific types of beds or services.
Unemployment Office Indiana - The form requests specific details regarding the separation to clarify the claimant’s eligibility.
What Is a Tax Exempt Certificate - Only certain employees of government entities are eligible to fill out and submit the ST-129.