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2Alaska WIC Rights and Responsibilities
You
have
rights
and responsibilities
as
a WIC participant. The names and addresses of you and
your
child may be
given
to agencies
such as
Medicaid, Denali Kid Care, Supplemental
Nutrition
Assistance Program (SNAP), Heating Assistance, Temporary Assistance, Child
Care,
Infant Leaming, Head Start
and
Public Health Nursing Programs
for
referral and outreach. Programs listed above may give the WIC
program
name(s), address,
income,
identification and
residency
for
you and your
child to help check
if you
qualify for WIC.
Other WIC information may
also
be
shared
with health programs
to
see
if you qualify for their program's
services,
to share needed health
information
with programs
you are already
participating in,
and
to help assess the overall health of Alaskan families
through
reports and
studies. These same
programs listed below may also share their
information
with
WIC
for the same
purposes.
You may
ask
WIC
staff
for
more information about these
programs.
These programs include: Medicaid, Denali Kid
Care,
Pro
Care, Head
Start,
Supplemental Nutrition
Assistance
Program
(Formally
known as the Food Stamp Program), Immunizations Program, Public
Health
Nursing,
State
Epidemiology and
Infant Leaming
Program.
I
understand my
Rights
and Responsibilities:
My Responsibilities. I agree to follow the rules below.
I
will:
•
Give
WIC true
and accurate
infonnation.
WIC staff can check this
information.
•
Immediately report any changes in my income, family size, address, phone number or eligibility for Medicaid/Denali Kid
Care,
or
the SNAP
Program.
I will also notify the WIC office
if
my checks
are
lost or
stolen, or
ifT am no longer
breastfeeding.
•
WIC
is
a Federal
program.
Ifl break the rules, make false statements, intentionally misrepresent,
conceal,
or withhold facts about
my
eligibility
for the WIC Program, I understand
that:
o
I
or my child can be taken
off
WIC.
o
I will have to pay money back to WTC for foods, formula or breast pumps I should not have
received.
If I do not
pay
b
ack
the WIC program for foods and/or formula that I accepted or return
loaned
breast ptnnps that l
was
not
eligible
to
receive,
the state may use other types of
legal
options
to
collect
payment, including
small
claims
court,
which could result in
Permanent
Fund Dividend (PFD) garnishment.
o
I can face
civil
or criminal prosecution under State and Federal law.
•
Get checks from only one clinic at a time.
If
I move out of Alaska, I will ask for a transfer.
•
Not sell, trade
or give away
formula, WIC foods, breast pumps or other WIC benefits.
•
Not
post WIC items
for
sale on the internet.
•
Not
trade my WIC
checks,
foods
,
or
formula for money, credit, rain checks or other items.
•
Be
removed
from the
WIC
program ifl do not pick up, use my checks, or fail to return
signed
receipts for WIC checks or food
boxes for two months in a row.
•
Treat
WIC
and store staff
with courtesy
and
respect.
•
Allow WIC
staff
to take my or my child's height and
weight
and
take
a
small
amount of blood to check
my
or my
child's
iron level.
I
understand this information is needed to check nutrition needs and determine eligibility for WIC.
•
Come to my appointments or call
ahead
when I need
to
reschedule.
•
Reapply for benefits as needed. I understand that WIC benefits
are
for participant
use
only.
•
Follow
the WIC program and shopping rules that are on my food list.
My Rights:
•
Ifl qualify for WIC, I will get checks to buy healthy foods.
I
understand that WIC does not give all the food or formula
needed in a month. WIC foods help promote and
support
the nutrition well-being and help meet the needed intake of important
nutrients or foods for myself and/
or
my child(ren).
•
WIC
will
give me information for healthy eating and active
living.
WIC will provide me
with
breast feeding
support.
•
WIC will
give
me information to find a doctor and get
immunizations
for my
child.
I
will be referred to other
services.
•
WIC
staff
will treat me
with
courtesy and respect.
•
WIC will keep information about me and
/
or my
child(ren)
confidential and
share
only needed information to determine eligibility
and for referral to other services.
•
The
rules
for getting on WIC
are
the
same
for
everyone.
I
can
ask for a Fair Hearing
if
I do not agree
with a
decision about my
WIC
eligibility.
WIC will tell me why my child or I qualify for the WIC Program.
By
signing this form
I
agree
that:
• I
have read the Rights and Responsibilities form or
a
WIC staff has read it to me.
•
I
agree to the
above.
Client/Guardian Signature Required for WIC Enrollment
Date
In
accordance
with
Federal civil
rights
Law and
Department
of Agriculture (USDA) regulations
and
policies, the
USDA,
its
Agencies,
offices, and
employees, and institutions participating
in or
administering
USDA
programs
are
prohibited
from
discriminating based
on race, color,
national origin,
sex,
disability, age,
or reprisal or
retaliation
for prior civil rights
activity
in
any program
or activity
conducted
or
funded
by USDA.
Persons
with
disabilities
who require alternative means of communication for
program information (
e.g.
Braille, large print,
audiotape, American Sign
Language,
etc.), should contact the Agency
(State or
local) where
they
applied
for benefits. Individuals
who are deaf,
hard of
hearing or have speech
disabilities
may
contact USDA through
the
Federal
Relay Service
at
(800) 877-8339. Additionally,
program
information may
be made available
in
languages
other than
English.
To file a program
complaint
of discrimination, complete the
USDA Program
Discrimination
Complaint Form, (AD-3027)
found
online at:
, and at
any
USDA office,
or
write a
letter
addressed
to
USDA
and provide in the
letter
all
of the
information requested in the form. To request
a
copy
of
the
complaint form, call
(866) 632-9992. Submit
your completed form
or letter to
USDA by
(
I)
Mail:
U.S.
Department of Agriculture, Office
of the
Assistant Secretary
for Civil
Rights,
1400 Independence
Ave., SW,
Washington, D.C. 20250-9410
or (2)
fax: (202) 690-7442;
or
(3) Email: program.intake@usda.gov.
o
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