1. 1. State Agency Referral Agreements and Coordination of Services
  2. 2. Local Agency Referral Procedures

1. State Agency Referral Agreements and Coordination of Services

  1. The State agency has written formal agreements that permit the sharing of participant information with the following programs/providers (indicate whether information is shared manually (M) or through ADP (A) by placing either an M or A in front of the appropriate service):
    • Reformatted for Internet Shared
      Food Stamp Program
      IHS facilities
      TANF
      Rural/migrant health centers
      Medicaid ADP
      Hospitals
      SSI
      Childhood immunization ADP
      EPSDT
      Immunization registries
      MCH programs ADP
      Well-child programs ADP
      Children with special health care needs program(s)
      Child protective services
      Children's health insurance
      Family planning Manually
      Private physicians
      other (specify): PTS, FWI Manually
  2. Formal agreements for coordination of services include:
    • ___Responsibilities of each party
    • ___Assurance that information is used for eligibility and/or outreach
    • ___Assurance that information will not be shared with a third party
  3. The State agency requires local agencies to coordinate services with, and/or develop referral systems for, the following (check all that apply):
    • Food Stamp Program - Checked
    • TANF - Checked
    • SSI - Checked
    • Medicaid - Checked
    • CHIP
    • IHS facilities - Checked
    • MCH (clinics/facilities) - Checked
    • EPSDT  - Checked
    • family planning  - Checked
    • prenatal care  - Checked
    • postnatal care  - Checked
    • immunization  - Checked
    • dental services  - Checked
    • private physicians  - Checked
    • hospitals  - Checked
    • well-child programs  - Checked
    • rural/migrant health centers  - Checked
    • children with special health care needs  - Checked
    • schools  - Checked
    • EFNEP  - Checked
    • other food assistance program (TEFAP, FDPIR, CSFP, etc.)  - Checked
    • breastfeeding promotion  - Checked
    • child protective services  - Checked
    • Head Start
    • Early Head Start
    • Healthy Start
    • child protective services  - Checked
    • child abuse counseling  - Checked
    • foster care agencies  - Checked
    • homeless facilities
    • substance abuse programs  - Checked
    • other (specify):

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

2. Local Agency Referral Procedures

  1. The State agency ensures that local agencies make available to all adults applying or reapplying for the WIC Program for themselves or on behalf of others the following types of information:
    • State Medicaid Program, including presumptive eligibility determinations, where available  - Checked
    • child support services  - Checked
    • Food Stamp Program  - Checked
    • substance abuse counseling/treatment programs  - Checked
    • TANF, including presumptive eligibility determinations, where available  - Checked
    • other State-funded medical insurance programs (specify): All Kids
    • other nutrition services (specify): food pantries, emergency feeding hospital dieticians, outpatient dieticians
    • EPSDT Program  - Checked
    • Children's Health Insurance program(s)  - Checked
    • Other (specify)
  2. The referral methods used by local agencies to other health and social service programs include (check all that apply and indicate the primary method of referral with an *):
    • State agency-developed referral forms
    • local agency-developed referral form  - Checked
    • telephone call to referring agency  - Checked
    • verbal referral to participants  - Checked
    • automated client/participant information exchange
    • written literature on referral programs  - Checked
    • follow-ups by staff to monitor  - Checked
    • maintain a list of local resources for drug and other harmful substance abuse counseling  - Checked
    • other (specify):
  3. Methods used by other health and social service programs to refer clients to the WIC Program include (check all that apply and indicate the primary method of referral with *):
    • WIC Program referral form  - Checked
    • health/social program referral form  - Checked
    • telephone call  - Checked
    • verbal referral  - Checked
    • automated client/participant information exchange
    • written literature on the WIC Program  - Checked
    • other (specify):
  4. The State agency has a system in place to monitor the extent to which WIC participants are using other health or social services (check all that apply):
    • Yes (check): - Checked
    • Medicaid - Checked
    • TANF - Checked
    • MCH - Checked
    • FSP  - Checked
    • Yes, other (specify):
    • No
  5. The State agency requires local agencies to monitor referrals to determine the extent of health or social services utilization in addition to State monitoring systems.
    • Yes
    • No  - Checked
    • ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
  6. In order to facilitate referrals to the Medicaid Program, the State agency provides each local agency a chart showing the maximum income limits, according to family size, applicable to pregnant women, infants, and children up to age 5 under the Medicaid Program.
    • Yes  - Checked
    • No
  7. The State agency assures that each local agency operating the Program within a hospital, and/or that has a cooperative arrangement with a hospital, advises potentially eligible individuals that receive inpatient or outpatient prenatal, maternity, or postpartum services, or that accompany a child under the age of 5 who receives well-child services, of the availability of program services.
    • Yes  - Checked
    • No
  8. The State agency ensures that, to the extent possible, local agencies provide an opportunity for individuals who may be eligible to be certified within the hospital for participation in WIC.
    • Yes  - Checked
    • No
  9. The State agency ensures that when WIC is at maximum caseload, local agencies make referrals to:
    • food banks  - Checked
    • food pantries  - Checked
    • soup kitchens or other emergency meal providers  - Checked
    • Food Stamp Program  - Checked
    • Commodity Supplemental Food Program  - Checked
    • Emergency Food Assistance Program  - Checked
    • Food Distribution Program on Indian Reservations
    • other (specify):
  10. The State agency ensures that when WIC is at maximum caseload, local agencies notify the State agency of any waiting lists established.
    • Yes  - Checked
    • No
  11. The State agency ensures that when WIC is at maximum caseload, local agencies notify FNS of any waiting lists established.
    • Yes  - Checked
    • No
  12. The State agency ensures that when the WIC participant's family has immediate needs for food beyond what WIC might provide, local agencies make referrals to:
    • food banks  - Checked
    • food pantries  - Checked
    • soup kitchens  - Checked
    • Food Stamp Program  - Checked
    • Emergency Food Assistance Program  - Checked
    • Food Distribution Program on Indian Reservations
    • other (specify):
  13. Immunization Screening and Referral
    • The State agency assures that each local agency is meeting the requirements of WIC Policy Memorandum #2001-7, August 30, 2001: Immunization Screening and Referral, as follows:
    • Screening children under the age of two using a documented immunization history:  - Checked
      • Using the minimum screening protocol; or
      • Using a more comprehensive means, (specify): See WIC PPM, Part 3, Section 15 Referral to other Services, Item #7 Immunization Screening and Documentation  - Checked
    • Using another program or entity to screen and refer WIC children using a documented immunization history; (specify): or
    • Implementing the minimum screening protocol is unnecessary because immunization coverage rates of WIC children by 24 months are 90% or greater; or
    • The State agency has been unable to formalize a coordination agreement with the State Immunization Program. Provide explanation of extenuating circumstances:
    • The State agency's policy and procedure manual has been updated to include the above immunization screening and referral protocol.
    • Yes  - Checked
    • No (explain):