proxyrevfinal[1].doc
DOC document 21 KB Posted
- Attached to
- Proxy Authorization
- Solicitation number
- RFQ - 18P - 07071200000000000004
- Issued by
- Androscoggin County, Penobscot County, Piscataquis County, Maine
About this file
This document is a Proxy Authorization form for the Maine WIC (Women, Infants, and Children) Program. The form allows a client to designate an adult proxy who can perform various tasks on the client's behalf, such as picking up and cashing WIC checks, bringing the client's child(ren) to WIC clinic appointments for follow-up or recertification. The proxy must understand how to cash WIC checks and the WIC nutritionist/counselor has the authority to deny the use of a proxy if they determine the parent/guardian must come to the clinic for WIC benefits.
The form outlines the client's consent to allow the designated proxy to act on their behalf, and the WIC staff's ability to release certain information about the client's WIC services, such as appointment times, food package prescriptions, iron test results, and weight and height measurements, to the proxy. The client understands they can change or cancel this request at any time.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| ADDRESSES[2].doc | DOC document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
State of Maine
WIC Program
PROXY AUTHORIZATION
A proxy must be an adult who can bring health care and other Program information back to the family. The proxy must understand how to cash WIC checks. The WIC nutritionist/counselor can deny the use of a proxy if she/he determines the parent/guardian must come to the clinic for WIC benefits.
I consent to allow _____________________________________ to act on my behalf to :
Yes No
· Pick Up WIC checks (Proxy must bring ID Folder)
· Cash WIC checks (signature must be on the WIC ID folder)
· Bring my child(ren) to the WIC clinic for follow-up appointments
· Bring my child(ren) to the WIC clinic for re-certification appointment ( I understand that WIC staff may release appointment time, information about the food package prescription, the results of the iron test, weight and height measurements and the results of the diet assessment to my proxy.
I understand that during a re-certification appointment WIC will weigh and measure my child and may take a finger stick sample of blood to test for iron.
I understand that I can change or cancel this request at any time.
Client/Authorized Representative Signature Date Signed
MWIC(rev 6/03) 102-00
File details come from the government source that posted it. Updated .