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Suffolk County, NY

Onlineforms@suffolkcountyny.gov

725 Veterans Memorial Highway, Smithtown, NY, 11787, US

631-555-1212

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Full Name

Date of Birth

Date Picker

Check the box to opt in for email contact.

Have you received WIC in the past?

Do you participate in any of the following? (Check all that apply)

Reason for Referral: (Check all that apply)

Completion and signing of this form indicates that consent has been obtained from the party named above for this referral and for contact to be made using the information provided.

The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant. For help with this form, or if you do not hear from a WIC clinic within two business days, please email: AskWIC@suffolkcountyny.gov.

HIPPA

WIC is not a HIPAA Covered Entity and is governed by federal regulations related to Personally Identifiable Information (PII). However, the WIC Referral System follows HIPAA protocols and procedures for data collection and storage. The application that stores the information entered into this form meets the security requirements required for HIPAA. Access to referral data is obtained through an electronic application. This application has role-based access and is only seen by WIC staff who would be following up with referrals or monitoring referral progress for WIC. In regards to a medical practitioner entering data for referral, the HIPAA Privacy Rule allows those doctors, nurses, hospitals, laboratory technicians, and other health care providers that are covered entities to use or disclose protected health information, such as X-rays, laboratory and pathology reports, diagnoses, and other medical information for treatment purposes without the patient’s authorization. This includes sharing the information to consult with other providers, including providers who are not covered entities, to treat a different patient, or to refer the patient (i.e. referral to WIC). See 45 CFR 164.506.

WIC Nondiscrimination Statement and Policy

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights 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: www.ascr.usda.gov/complaint_filing_cust.html, 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 (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider. For other complaints, contact: (1) mail: WIC Program Director NYSDOH, Riverview Center Room 650, 150 Broadway, Albany, NY 12204; or (2) phone: The Growing up Healthy Hotline at 1-800-522-5006; or (3) email: NYSWIC@HEALTH.NY.GOV