Wic Program Application - Meigs County Health Department (Page 2 of 2) in pdf

By signing this WIC application, I agree to give proof of eligibility

I have provided on this form to enable the departments to

for information entered on this form and any other information

determine my eligibility.

asked to meet program rules.

I understand that this application is considered without regard to

I authorize any person who furnishes me with health care or

race, color, national origin, sex, age, or disability.

medical supplies to give the Ohio Department of Job and Family

By my signature below, I affirm under penalty of perjury that to the

Services or the Ohio Department of Health any information related

best of my knowledge and belief all the answers on this application

to the extent, duration, and scope of services provided to me under

are true and complete. I understand that the law provides penalty

the Medicaid, WIC, and other medical assistance programs.

of fine or imprisonment (or both) for anyone convicted of accepting

I also authorize the Ohio Department of Health and the Ohio

assistance he or she is not eligible to receive.

Department of Job and Family Services to exchange any information

Signature of applicant who completed this form

Date of signature

Signature of person who helped complete this form

Date of signature

GENCY

NLY

Pregnancy Verification

Medical statement attached

Medical chart location (office name)

Patient name and number

Telephoned (name)

Agency/Business

Call date

Verification statement

Identification Verification

Name ( Circle one—

)

Document type or number

I C P N B

Present

Exempt

Name ( Circle one—

)

Document type or number

I C P N B

Present

Exempt

Name ( Circle one—

I C P N B

)

Document type or number

Present

Exempt

Name ( Circle one—

I C P N B

)

Document type or number

Present

Exempt

Medical chart location (office name)

Income Verification

Verification attached (county department of job and family services, employer, other agencies)

Check those that apply

Economic unit size

OWF

Disability Assistance

Food Assistance

Medicaid

Refugee

Card number

Effective date

Medicaid

Food Assistance

Verification statement used

Statement date

Income amount

(document/check stub/letter)

Weekly x 4.3

Biweekly x 2.15

Yes

Semimonthly x 2

Monthly

Telephoned (name)

Agency/Business

Call date

Confirmed or other information

Proof of Residence

Ohio License /ID

Utility /credit bill

WIC Reminder Card

Medical card /JFS document

Other _________________________________________

WIC personnel signature

Date

This Institution is an equal opportunity provider.

Wic Program Application - Meigs County Health Department Page 2

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