WIC Forms

When you participate in WIC, staff will ask you for some information. Some forms are required to participate. WIC staff will let you know if you need to fill out any of these forms.

Do you want to do your WIC appointment from home instead of coming into Adelante Healthcare?
Please contact us at 1.877.809.5092 for more information.

Adelante WIC Patient Forms

WIC Rights and Responsibilities

WIC Rights and Responsibilities Spanish

Voter Registration

Pump Loan Agreement

Statement of Documentation

Statement of Documentation Spanish

Change of Authorized Rep

Change of Authorized Rep Spanish

Language Access Waiver

Language Access Waiver Spanish

Notice of Ineligibility

Notice of Ineligibility Spanish

Proxy Certification

Proxy Certification Spanish

AZ Referral & physical presence Exemption Form

 

Note:  All Forms require the free version of Adobe Reader for viewing and printing. Download a free copy of Adobe Reader here.

Click here to view forms in more languages.

 

 

X