The Wisconsin F 40052A form is a document used to order breast pumps through the Wisconsin WIC Program. It allows participants to specify the type and quantity of breast pumps and accessories needed, ensuring that families have access to essential breastfeeding support. For those interested in completing this form, please click the button below.
The Wisconsin F 40052A form plays a vital role in the state's Women, Infants, and Children (WIC) program by facilitating the ordering and distribution of breast pumps and related accessories. Designed for use by healthcare providers and WIC program administrators, this form helps ensure that eligible families receive the necessary equipment to support breastfeeding. Each section of the form requires specific information, including the project number and the order period, which is divided into four quarters throughout the year. Users can select from a range of products, including multi-user rental electric pumps, personal electric pumps, and various manual pumps, along with optional accessories like breastshields and pumping kits. The form emphasizes the voluntary nature of its completion, while also clearly stating that the collected information will be used solely for ordering and shipping purposes. To streamline the process, completed forms can be mailed or faxed to the Wisconsin WIC Program’s Nutrition Section. By understanding the details of the F 40052A form, healthcare providers can better serve their clients and promote successful breastfeeding practices across the state.
The Wisconsin F 40052A form is used to order and ship breast pumps and related accessories for participants in the WIC (Women, Infants, and Children) program. Completing this form ensures that clients receive the necessary equipment to support breastfeeding.
This form can be filled out by WIC program staff or authorized representatives. It is important that the person completing the form has the appropriate information about the client’s needs and the specific products being ordered.
You can submit the completed form by mailing it to the Wisconsin WIC Program at the address provided: Nutrition Section, PO Box 2659, Madison, WI 53701-2659. Alternatively, you may fax it to 608-266-3125. Ensure that all sections are filled out accurately to avoid any delays in processing.
The form allows for the ordering of various breast pumps, including multi-user rental electric pumps, personal electric pumps, and manual pumps. Additionally, optional accessories such as breastshields and pumping kits can also be ordered. Each item has specific ordering units, so be sure to check the details carefully.
If your shipping information has changed since your last order, you should provide the updated details on the form. This includes your street address, city, and zip code. Accurate shipping information is crucial to ensure that the ordered items reach you without any issues.
When filling out and using the Wisconsin F 40052A form, it is important to keep the following key takeaways in mind:
Wisconsin F 62019 - Individuals listed as owners must disclose their percentage of ownership interest.
For those seeking to understand the intricacies of a properly drafted Durable Power of Attorney, it is crucial to recognize how this document can facilitate vital decision-making processes during times of incapacity. This form ensures that your selected agent is equipped to act in your best interests, safeguarding your wellbeing and financial matters.
Individual Service Plan Template - Signatures from the participant, guardian, and service coordinator are required for validation.
Understanding the Wisconsin F 40052A form can be challenging due to common misconceptions. Here are eight of those misconceptions explained:
Clarifying these misconceptions can help participants better understand how to utilize the Wisconsin F 40052A form effectively.
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Community Health Promotion
F-40052A (09/2013)
WISCONSIN WIC BREAST PUMP ORDER
Order Period and Due Date (check one)
Project Number:
1st
Quarter
2nd Quarter
3rd Quarter
4th Quarter
December 7
March 7
June 7
September 7
Project Name:
Completion of this form is voluntary. Information collected will be used to order and ship client material. Mail the completed form to Wisconsin WIC Program, Nutrition Section, PO Box 2659, Madison, WI 53701-2659, OR fax to 608-266-3125.
Manufacturer/Product
Product Name
Quantity
M E D E L A
Multi-User Rental Electric Pump
Lactina Select
Units
► Order unit: each
Personal Electric Pump
WIC Personal Double Pump Advanced
Case
► Order unit: per case (3 per case)
(Two-Phase)
Battery Pack for Personal Electric Pump
Battery Pack
Double Pumping Accessory Kit
Lactina Double Kit with two 24 mm and
► Order unit: per case (20 per case)
two 27 mm Personal Fit breastshields
Manual Pump
WIC Harmony with one 24 mm and one
27 mm Personal Fit breastshields
O p t i o n a l A c c e s s o r i e s
Large [30-31 mm] Breastshields
► Order unit: per case (12 per case)
Extra Large [36 mm] Breastshields
A M E D A
Reconditioned Elite
Personal Electric Pump with internal battery
Purely Yours
Dual Hygienikit with Custom Fit Flanges
(25, 28.5 and 30.5 mm)
Ameda One-Hand with Custom Fit
Flanges (22.5, 25, 28.5 and 30.5 mm)
Large Flange (30.5 mm/28.5 mm inserts)
Extra Large Flange (36 mm/32.5 mm inserts)
Project No.
HYGEIA
EnJoye LBI (with internal battery and
► Order unit: per case (2 per case)
personal accessory kit)
EnRiche Q with personal accessory kit
External Battery Pack
► Order unit: per case (10 per case)
EnJoye/EnRiche Accessory Kit
Personal Accessory Kit with Flanges
(2) 27- 28 mm and (2) 30-31 mm
Piston hand pump with Flanges
(1) 27- 28 mm and (1) 30-31 mm
Extra Large Flange (36 mm)
Provide your shipping information ONLY if it has changed since your last order.
Street Address:
City:
Zip Code:
Primary Contact Person:
Area Code and Telephone:
Email form to: WIC Nutrition Program