This form is to be used by clients who do not wish for their information to be automatically shared with the Wyoming Women, Infants & Children (WIC) Program. The Wyoming WIC Program offers benefits to low-income women who are pregnant, breastfeeding, or who just had a baby, and families with children under the age of 5. Nutritious food items, as well as many other benefits, are available for many Wyoming families through WIC. Medicaid state agencies must restrict the use or disclosure of information concerning Medicaid applicants and beneficiaries to purposes directly connected with the administration of the state plan under section 1902(a)(7) of the Act and implementing regulations at 42 CFR part 431, subpart F. Sharing data with a WIC state or local agency in order to facilitate or modernize coordination efforts required under Sections 1902(a)(11)(C) and 1902(a)(53) of the Social Security Act, is a purpose directly related to the administration of the state plan.  Any release of information from the state Medicaid agency to the WIC state agency must comply with all Medicaid confidentiality requirements at 42 CFR § 431.306(b)). 

Please note if you visit a WIC office and let them know you are a Medicaid or CHIP client, they will verify your Medicaid eligibility with us through a non-automated mechanism. This opt-out will not impact that process.

Please provide the following information if you wish to opt out of having your Medicaid application information shared with WIC:

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