Fill Out a Valid Wisconsin F 40052A Template Edit Form Online

Fill Out a Valid Wisconsin F 40052A Template

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.

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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.

Listed Questions and Answers

  1. What is the purpose of the Wisconsin F 40052A form?

    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.

  2. Who can fill out the F 40052A form?

    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.

  3. How do I submit the completed F 40052A form?

    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.

  4. What types of breast pumps and accessories can be ordered using this form?

    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.

  5. What should I do if my shipping information has changed?

    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.

Key takeaways

When filling out and using the Wisconsin F 40052A form, it is important to keep the following key takeaways in mind:

  • The form is used to order breast pumps through the Wisconsin WIC Program.
  • Completion of the form is voluntary, but necessary for processing orders.
  • Choose the appropriate order period by checking one of the four quarters: 1st, 2nd, 3rd, or 4th.
  • Provide accurate project information, including the project number and project name.
  • Specify the manufacturer and product name, along with the desired quantity for each item.
  • Mail the completed form to the designated address or fax it to the provided number for quicker processing.
  • Shipping information should only be provided if it has changed since the last order.
  • Optional accessories can be ordered, and their quantities should also be clearly indicated.
  • Ensure that all contact information is accurate to facilitate communication regarding the order.

Document Overview

Fact Name Details
Form Title Wisconsin WIC Breast Pump Order
Form Number F-40052A
Revision Date 09/2013
Governing Body Wisconsin Department of Health Services
Purpose This form is used to order and ship breast pumps for WIC clients.
Submission Methods Completed forms can be mailed or faxed to the Wisconsin WIC Program.
Order Periods Orders can be placed for four quarters: December, March, June, and September.
Manufacturer Options Includes products from Medela, Ameda, and Hygeia.
Optional Accessories Various breastshield sizes and accessory kits are available for order.
Voluntary Completion Filling out this form is voluntary, but necessary for processing orders.

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Misconceptions

Understanding the Wisconsin F 40052A form can be challenging due to common misconceptions. Here are eight of those misconceptions explained:

  • The form is mandatory for all WIC participants. Many believe that completing the F 40052A form is required for all participants. In reality, completing this form is voluntary, and it is used primarily to order and ship breast pumps.
  • Only certain types of breast pumps can be ordered. Some individuals think that the form restricts them to a limited selection. However, the form includes a variety of options, including multi-user rental electric pumps and personal electric pumps.
  • Submission of the form is limited to mail only. A misconception exists that the form must be mailed to the Wisconsin WIC Program. In fact, the form can also be faxed to the provided number, offering more flexibility for submission.
  • All orders must be placed at the beginning of each quarter. Some may assume that orders can only be placed at the start of a quarter. However, the form allows for orders throughout the quarter, as long as they are submitted by the due date.
  • There is no limit to the quantity of pumps that can be ordered. People often think they can order as many pumps as they want. In reality, the form specifies quantity limits for different types of pumps and accessories.
  • Only one type of breast pump can be ordered at a time. It is a common belief that participants must choose just one type of pump per order. In truth, multiple types can be included on the same form, facilitating a more comprehensive order.
  • The form is only for new participants. Some individuals think that the F 40052A is exclusively for new WIC participants. However, existing participants can also use the form to reorder supplies as needed.
  • Shipping information is not important. A misconception is that providing shipping information is optional. It is crucial to provide accurate shipping details, especially if they have changed since the last order, to ensure timely delivery.

Clarifying these misconceptions can help participants better understand how to utilize the Wisconsin F 40052A form effectively.

Form Sample

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

 

Units

Order unit: each

 

 

 

 

 

 

 

 

 

Double Pumping Accessory Kit

 

Lactina Double Kit with two 24 mm and

 

Case

Order unit: per case (20 per case)

 

two 27 mm Personal Fit breastshields

 

 

 

 

 

 

 

Manual Pump

 

WIC Harmony with one 24 mm and one

 

Case

Order unit: per case (20 per case)

 

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

 

 

 

Case

Order unit: per case (12 per case)

 

 

 

 

Extra Large [36 mm] Breastshields

 

 

 

Case

Order unit: per case (12 per case)

 

 

 

 

 

 

 

 

 

A M E D A

 

 

 

 

 

 

 

 

 

Multi-User Rental Electric Pump

 

Reconditioned Elite

 

Units

Order unit: each

 

 

 

 

Personal Electric Pump with internal battery

 

Purely Yours

 

Units

Order unit: each

 

 

 

 

Double Pumping Accessory Kit

 

Dual Hygienikit with Custom Fit Flanges

 

Case

Order unit: per case (20 per case)

 

(25, 28.5 and 30.5 mm)

 

 

Manual Pump

 

Ameda One-Hand with Custom Fit

 

Case

Order unit: per case (20 per case)

 

Flanges (22.5, 25, 28.5 and 30.5 mm)

 

 

O p t i o n a l A c c e s s o r i e s

 

 

 

 

Large Flange (30.5 mm/28.5 mm inserts)

 

 

 

Case

Order unit: per case (12 per case)

 

 

 

 

Extra Large Flange (36 mm/32.5 mm inserts)

 

 

 

Case

Order unit: per case (12 per case)

 

 

 

 

F-40052A (09/2013)

 

Project No.

 

 

 

 

 

 

 

 

 

 

 

 

HYGEIA

 

 

 

 

 

 

 

 

 

Multi-User Rental Electric Pump

 

EnJoye LBI (with internal battery and

 

Case

Order unit: per case (2 per case)

 

personal accessory kit)

 

 

 

 

 

 

 

Personal Electric Pump

 

EnRiche Q with personal accessory kit

 

Case

Order unit: per case (2 per case)

 

 

 

 

 

 

 

 

 

External Battery Pack

 

External Battery Pack

 

Case

Order unit: per case (10 per case)

 

 

 

 

 

 

 

 

 

EnJoye/EnRiche Accessory Kit

 

Personal Accessory Kit with Flanges

 

Case

Order unit: per case (20 per case)

 

(2) 27- 28 mm and (2) 30-31 mm

 

 

 

 

 

 

 

Manual Pump

 

Piston hand pump with Flanges

 

Case

Order unit: per case (20 per case)

 

(1) 27- 28 mm and (1) 30-31 mm

 

 

 

 

 

 

 

O p t i o n a l A c c e s s o r i e s

 

 

 

 

Extra Large Flange (36 mm)

 

 

 

Case

Order unit: per case (20 per case)

 

 

 

 

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