The NYC WIC Medical Referral Form, DOH-799, is a one-page document your healthcare provider completes so WIC can assess your nutritional risk and assign the right food package. You can download it from the New York State Department of Health website or pick up a copy at any local WIC office.1New York State Department of Health. WIC Medical Referral Form A doctor, nurse practitioner, or physician assistant fills in the clinical sections; you sign the release; you bring it to your WIC certification appointment.
The form collects height, weight, bloodwork, and pregnancy or growth data. WIC staff use those numbers to decide what benefits you qualify for, so every field matters and the measurements have to be fresh.
What Your Provider Fills In
Section A captures the patient’s name, date of birth, sex, address, phone, and preferred language. For a child, the parent or guardian’s name goes here too. Your local WIC office may stamp its agency information in this section before giving you a blank form, or leave that area for staff to complete later.1New York State Department of Health. WIC Medical Referral Form
Section B is the clinical core, and it has three tracks depending on who the patient is.
Women
The provider records current height and weight, hemoglobin (g/dL) or hematocrit (%) with the date each was measured, the number of previous pregnancies and deliveries, and the date prenatal care began. For a pregnant patient, add the estimated delivery date, number of fetuses, and pre-pregnancy weight. For a postpartum patient, add the delivery or termination date and total gestational weight gain.1New York State Department of Health. WIC Medical Referral Form
Infants and Children Under 24 Months
Birth length, birth weight, weeks of gestation, current length and weight, hemoglobin or hematocrit, venous lead level, and whether immunizations are up to date.1New York State Department of Health. WIC Medical Referral Form
Children Ages Two Through Five
Similar fields to the under-24-months group, minus the birth measurements and gestation data.
The 60-Day Rule
Height, weight, and bloodwork on the DOH-799 cannot be older than 60 days at the time of your WIC appointment. If the numbers are stale, WIC will send you back to the provider for updated measurements. Time the medical visit so the data is recent but not so early that it ages out before your WIC appointment.1New York State Department of Health. WIC Medical Referral Form
Diagnoses and Nutrition Concerns
Section C is open-ended. Your provider notes any significant medical diagnoses, health history, chronic conditions that affect diet, food allergies, developmental issues, or nutrition counseling topics they want the WIC nutritionist to address.
Provider Signature
In Section D, the provider prints their name, signs, dates the form, and lists their office address, phone, and fax. WIC staff may call the provider to clarify clinical details, so the contact information has to be legible.1New York State Department of Health. WIC Medical Referral Form
What You Sign
Section E is the release of information. The patient, or a parent or guardian for a child, signs and dates this section to authorize the provider to share the medical information on the form with WIC. Without this signature, the WIC office cannot use the clinical data to process your benefits.
When You Also Need Form DOH-4456
If a participant needs a non-standard infant formula, medical nutritional product, or supplemental food because of a qualifying medical condition, the provider fills out a second form: the WIC Medical Documentation Form, DOH-4456. It supplements the DOH-799; it does not replace it.
The prescribing provider must select at least one qualifying medical condition from a list on the form. Accepted conditions include developmental delay, dysphagia, failure to thrive, gastrointestinal diseases, immune system disorder, low birth weight (under 24 months only), malabsorption syndromes, metabolic disorders, premature birth (under 24 months only), and severe food allergies. Common symptoms like fussiness, gas, spitting up, colic, constipation, diarrhea, vomiting, dermatitis, and general formula intolerance are explicitly listed as not acceptable on their own.2New York State Department of Health. WIC Medical Documentation Form
The provider must also specify the exact product name (it has to appear on the New York State WIC Formulary), the product form (powder, concentrate, or ready-to-feed), a prescribed daily amount in ounces (vague instructions like “ad lib” or “as tolerated” are rejected), and the length of use. For children and women, the maximum approval period is 12 months.2New York State Department of Health. WIC Medical Documentation Form
What to Bring to the WIC Appointment
The completed DOH-799 is one of several documents you need. Forgetting any category can mean rescheduling.
Proof of income. A Medicaid card with your Client Identification Number, a SNAP or TANF notice listing all household members, pay stubs or direct deposit records from the past 30 days for every working household member, or documentation of other income such as Social Security, unemployment, child support, or pension payments. If you have no income, you sign a statement at the office.3New York State Department of Health. What to Bring to Your WIC Appointment
Proof of categorical status. For pregnant patients, the completed DOH-799, a signed provider statement with the expected delivery date, or a dated ultrasound image with the patient’s name. For breastfeeding patients and those with an infant under six months, the DOH-799, a provider statement, or hospital discharge papers. For infants and children, the DOH-799, a birth certificate, or hospital records.3New York State Department of Health. What to Bring to Your WIC Appointment
Proof of identity. A photo ID such as a driver’s license, military ID, or school or employment ID, or a non-photo document like a birth certificate, passport, permanent resident card, or Social Security card.
Proof of New York residency. A current rent or mortgage document, a utility or cell phone bill, a pay stub showing your address, or official mail with a recent postmark.3New York State Department of Health. What to Bring to Your WIC Appointment
Submitting the Form
Most people hand-deliver the DOH-799 at their certification appointment. WIC staff review the medical data on the spot, run the nutritional risk assessment, and set up your eWIC card if you qualify. The card works like a debit card at authorized grocery stores and pharmacies.4ACCESS NYC. Women, Infants, and Children (WIC)
Many local offices also accept the form by fax or mail. Some have secure upload options, though availability varies. Call your local WIC agency ahead of time to confirm which methods they support and whether sending the form in early can speed up your visit.
To find the nearest WIC office, use the directory on the Department of Health website or call the Growing Up Healthy Hotline at 1-800-522-5006. WIC’s 24/7 virtual chat assistant, “Wanda,” runs a brief eligibility screening and refers you to a local office in about three minutes.5New York State Department of Health. Offices (Local Agencies) That Provide WIC Services
Mistakes That Get the Form Rejected
The most common issue is a blank field. The hemoglobin or hematocrit result, the date measurements were taken, and the provider’s signature are the usual culprits. Any of those missing means a trip back to the doctor’s office before WIC can process your application.
Stale measurements are the other frequent problem. If your provider took the height and weight 65 days before your WIC visit, those numbers fall outside the 60-day window and the form will be sent back.
For specialized formula requests on Form DOH-4456, the top reasons for rejection are listing a symptom (like fussiness or gas) instead of a qualifying medical diagnosis, writing “ad lib” instead of a specific daily ounce amount, or requesting a product that is not on the New York State WIC Formulary. Check all three before the provider signs.2New York State Department of Health. WIC Medical Documentation Form
When You’ll Need a New DOH-799
WIC benefits run on fixed certification periods, and recertification means a new DOH-799 with fresh measurements. Pregnant participants are certified through the pregnancy, ending the last day of the month the infant turns six weeks old or the pregnancy ends. Postpartum participants who are not breastfeeding are certified up to six months after delivery. Breastfeeding participants are certified up to the last day of the month the infant turns one year old, or until breastfeeding stops. Infants and children ages one through four are certified roughly every six months, though the state may extend that period.6eCFR. 7 CFR 246.7 – Certification of Participants
A change in status also calls for a new referral form before the certification period expires. Moving from pregnant to postpartum, or from breastfeeding to non-breastfeeding postpartum, changes the food package you receive and requires updated clinical information. When your recertification date approaches, book the provider visit with the 60-day window in mind.