dch-1320, MI-wic eligibility intake offline template

Michigan Department of Health and Human Services (MDHHS)

(New 6-24)

To be completed by WIC Clerical Staff.

Family ID	Date	Staff

section 1 - family information

Authorized Person Name
Last Name	First Name	Birth Date
Referred by

Client Name	Medicaid Number	Birth Date	Cat	Appt Type	ID (if new)	Race/ Ethnicity (if new)	Proof PG	EDU Level	Marital Status	Foster Child

section 2

Proxy Keep the same Declined Proxy

1. Last Name	First Name

2. Last Name	First Name

Same as Street Address (complete below if not)

Street Address	Mailing Address Receive Mailed Notifications

No Phone

Phone Number	Comment	Primary	Type	Text	Voice Calls

Email	No Email

Language English Spanish Arabic Other (list) Add note Translator Required

Proof of Residency MIHealth Card MI Bridge Card Driver’s License MI ID Voter Registration Utility/Rent Receipt WIC VOC Passport/VISA Homeless Shelter Other No Source of Residency No Proof

Voter Registration Yes, form given No, declination obtained No, registered at present address Address change, form given Under age 18

Internet Access Yes No Unknown	Migrant Yes No	Homeless Yes No

Proof of Authorized Person ID Birth Certificate Bridge card (DHS or WIC) Crib card/hospital record Driver’s License Health Insurance Immigration papers Immunization Record Medicaid card MI ID Card Passport Pay stub with Name Photo ID Social Security Card Student ID Card Voter Registration Card WIC records from other State Work or school ID card Other None: No Proof process required

Adjunct Eligibility

Medicaid Yes No	SNAP/Food Stamps Yes No	FIP Yes No

Income

Family Size = + Number of Expected Infants = Total =

Source	Interval (Hourly x 2080, Biweekly x 26, Monthly x 12)	Amount	Annual Total

Gross Wages
FIP
SSI
Child Support
Cash from Family
Unemployment
Other
Total

No Income (Complete questions below)

Where are you and or your children staying?

Who provides food for you and/or your children?

How long have you been without income?

A signed client agreement is considered the attestation for no income.

Is family income eligible Yes No

New EBT card Provided: 5077118

Replacement Reason Defective Damaged Lost Stolen

section 3 - Family Health Questions (To be completed by WIC CPA staff).

Are you or your children regularly exposed to secondhand smoke? Yes, all Yes, who No Unknown/Refused

Does your family regularly visit a dentist? Yes, all Yes, who No

In the last 6 months, has anyone in the family entered foster care or changed foster homes? Yes, all Yes, who No

Is the water in your home safe for drinking and food preparation? Yes No, but it is safe if I flush/filter No, but I get my water from a different source No, but I use it anyway Unknown

Do you or your child’s caregiver have any condition that would affect their ability to make feeding decisions or prepare food? Yes No

Are you ever worried about not having enough food to feed your family? Yes No

Do you have any concerns about the safety of you and your children? Yes, concerned and actively the recipient of abuse Yes, concerned but not the recipient of abuse No Unknown/Refused

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.
This institution is an equal opportunity provider.