636 Medical Doc

picture2_636 Medical Doc picture3_636 Medical Doc

89x Filetype PDF File size 0.17 MB Source: www.oregon.gov

File: 636 Medical Doc

Local WIC Clinic: Women, Infants and Children (WIC) Phone #: Medical Documentation Form Fax #: Contact Name: • This request is subject to WIC approval and provision based on program ...

Filetype PDF | Posted on 15 Jan 2023 | 2 years ago

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...Local wic clinic women infants and children phone medical documentation form fax contact name this request is subject to approval provision based on program policy procedure please or return the completed your patient must be under supervision of provider signing a information s last first mi dob parent caregiver number i am requesting nutrition assessment consult by dietitian nutritionist for b formula some all provided via tube feeding refer medicaid diagnosis qualifying condition length issuance months until age other not exceed prescribed amount per day maximum allowable c supplemental foods will unless indicated below determine older than adults omit milk cheese eggs peanut butter infant cereal include in place breakfast jarred fruits vegs fresh produce vegetables whole lower fat with receiving no exceptions additional instructions d health care signature print md do np pa nd cnm office date received exp rdn review id use warehouse only order http www healthoregon org questions re...

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Category: Uncategorized / Uncategorized
Posted on: 15 Jan 2023 | 2 years ago
Tag: download pdf, medical,
Filetype: PDF
File size: 0.17 MB
Views: 89x
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