Request for Information.doc
DOC document 29 KB Posted
- Attached to
- Request for Information - Women
- Solicitation number
- RFQ - 18P - 07071100000000000003
- Issued by
- Androscoggin County, Penobscot County, Piscataquis County, Maine
About this file
This document is a Request for Information (RFI) issued by the Women, Infants and Children (WIC) program of the State of Maine. The RFI is seeking information from healthcare providers to determine the eligibility of individuals for the WIC nutrition program. The RFI requests information on the client's health status, including details on medical conditions, laboratory test results, and any special dietary requirements. The healthcare provider must complete the form and return it to the WIC program. The client's consent is required to authorize the release of this information, and the consent is effective for up to 30 months.
The RFI does not provide any details on a state or local contract opportunity. It is solely focused on gathering information to determine WIC program eligibility for individual clients.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| ADDRESSES[1].doc | DOC document | |
| Conditions and Instructions to Bidders.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 RETURN TO:
WIC PROGRAM
REQUEST FOR INFORMATION
To: ______________________________________________________
Address: ______________________________________________Phone: ________________Fax: ______________
Client name: ____________________________________________ DOB_______________ID #_________________
Address: _______________________________________________________ WIC Clinic # ____
WOMAN
Doctor’s Office Use Only
This information will be used to determine eligibility for the Women, Infants and Children (WIC) nutrition program.
___ Please complete:
( Hct/Hgb _________ Date taken __________
( EDD ________________
( Lead level __________ Date taken ____________
___ Please check or list current medical condition and/or history of a medical condition that may affect nutritional status:
( Diabetes Mellitus ( Gestational Diabetes ( Hypertension
( Blood transfusion during delivery or ( Current multiple gestation within 6 weeks postpartum ( Fetal growth restriction
( Hx of miscarriage, stillbirth, neonatal death, ( Food allergies (specify): _________________ spontaneous abortion (date ____________) ______________________________________
( Hx of birth w/congenital or birth defect
( Recent surgery, trauma or severe acute
( Hx of LBW birth ( < 2500 gm ) infections (within 2 months)
( Hx of pre-term delivery ( < 37 wk. )
( Special diet (specify)____________________
( Other (specify)_________________________ ______________________________________
Health Provider’s Signature: ________________________________________ Date: ____________
Client Authorization My consent to authorize the release of this information is effective until _____________. (not to exceed 30 months)
· The WIC program MAY MAY NOT call my physician about this request within the effective date.
· I DO DO NOT authorize the WIC program to re-release this information.
· I understand that I can revoke my consent at any time before the above expiration date by bringing a written, signed and dated note of my wishes to the local WIC program. This will not affect any information the health care provider releases before WIC receives the note. A decision to withdraw any consent to release the requested information, however, may mean that the WIC program will not have the information needed to provide WIC benefits.
· I can refuse to authorize the release of some or all of the information requested, but if I do this, it could mean that the WIC program will not have the information needed to provide WIC benefits.
· I am entitled to a copy of this request form.
Signed: ____________________________________________ Date:_____________________
WIC Participant/Parent/Guardian
Signed:_____________________________________________ Date:______________________
WIC Program Representative
(BHWIC-039B)rev 4/00
File details come from the government source that posted it. Updated .