Participant Rights and Responsibilities

As a Pennsylvania WIC Program participant, I understand the following:
1. Standards for eligibility and participation are the same for everyone regardless of race, color,
national origin, age, sex, or disability. Race/ethnicity information is collected for statisticalreporting only and does not affect my participation in the WIC Program.
2. I may appeal any decision made by WIC regarding my or my child's eligibility.
3. By providing consent during the nutrition assessment, WIC has permission to share my or mychild's information with our designated health care provider.
4. I will receive nutrition information and referrals to health services. I am encouraged toparticipate in these services.
5. I will receive instructions on how to use WIC benefits.
6. I will keep my WIC appointments or contact the WIC clinic to reschedule. If I fail to pick up myWIC benefits for 3 months in a row, I will be terminated from the WIC Program.
7. I will only participate in one WIC clinic at a time. Receiving WIC benefits from two clinics or twostates during the same month will result in my disqualification from the WIC Program.
8. WIC participants who sell or exchange privately purchased (not purchased with WIC benefits)
food or formula identical to the food or formula prescribed to them by the WIC Program mustretain sales receipts for those items to document they are not selling or exchanging food or
formula provided by the WIC Program.
9. I have the right to file a complaint against a retail store by contacting my Local Agency RetailStore Coordinator. I may choose to remain anonymous.
10. I am protected under the Americans with Disabilities Act and Section 504 of the Rehabilitation
Act of 1973. If I feel these rights have been violated, I can file a complaint by contacting theState Agency at (717) 783-1289.
11. WIC may verify any information I have provided. If I provide false or misleading information, I
may have to pay back to WIC, in cash, the value of the food benefits improperly issued to me.
Also, I may be subject to civil or criminal prosecution under State and Federal law.
12. The Secretary of Health may allow release of information I have given to WIC to other programs
such as CHIP, Medical Assistance, SNAP, School Breakfast and School Lunch. The
information will only be used to determine my eligibility for these programs and for outreach.

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13. The Secretary of Health has authorized the use and disclosure of information about yourparticipation in the WIC Program to the Maternal Mortality Review Committee (MMRC), which is a
non-WIC purpose. MMRC is a group of professionals and partners who work to improve pregnant
and postpartum health, and who collectively review pregnancy associated deaths to determine
whether the death was related to the pregnancy, if it was preventable and what factors contributed
to the death. MMRC will use your information only in the administration of its program.
14. The Secretary of Health has authorized the use and disclosure of information about yourparticipation in the WIC Program to the Pennsylvania Department of Human Services (DHS), which
is a non-WIC purpose. DHS will use your WIC Program information to assist in the administration ofits Medical Assistance (“MA”), also known as Medicaid, program to identify possible MA individuals
who are not participating in WIC and to analyze statistical trends of individuals who participate inMA, but not WIC. DHS will use your information only in the administration of its program.
15. The Secretary of Health has authorized the use and disclosure of information about yourparticipation in the WIC Program to the Pennsylvania Pregnancy Risk Assessment Monitoring
System Project (PRAMS), which is a non-WIC purpose. PRAMS is a joint research project between
the Pennsylvania Department of Health, Bureau of Family Health and the Centers for Disease
Control and Prevention (CDC). PRAMS goal is to improve the health of future mothers, pregnantpeople, and babies, which it does by collecting information through surveys from new mothers inPennsylvania. PRAMS will use your information only in the administration of its program.
16. My or my child's file may be reviewed by a third party (non-WIC) auditor as part of the WIC
annual audit. All information is confidential.

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Participant Rights and Responsibilities

I agree to follow the rules below. I will:
1. Give correct and truthful information.
2. Redeem WIC benefits within the allowable dates.
3. Redeem WIC benefits for only WIC approved foods.
4. Keep my eWIC card in a safe place.
5. Report lost or stolen eWIC cards to the WIC clinic immediately.
6. Bring my eWIC card to every WIC appointment. If I forget my card, my family will not receive
benefits at that appointment.
7. Bring my children and their shot records to every certification appointment.
8. Bring proof of identity, proof of address, and proof of household income to every certification
appointment.
9. Notify WIC of any changes in my child's custody agreement or address immediately.
10. Choose a person (proxy) to pick up and redeem my WIC benefits if I am not able to get to theWIC clinic or grocery store. My proxy will have to be trained by WIC staff on how to use WIC
benefits. If my proxy does anything wrong with my WIC benefits, I may be disqualified fromparticipating in WIC.
11. Treat WIC and grocery store staff with courtesy.
12. Return an electric rental breast pump received from WIC by the established due date.
13. Not sell, lend, or exchange a breast pump received from WIC.
14. Not give away WIC benefits, food, or formula.
15. Not sell or exchange, including online, WIC benefits, food, or formula for cash, credit, or otheritems.

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16. Not write my eWIC PIN on my card or keep it with the card.
17. Not share my eWIC PIN with anyone other than my WIC approved proxy.
18. Not throw away my eWIC card. Future benefits will be added to the card I set up at my first WIC
appointment.
19. Not tamper with my eWIC card.
20. Not redeem WIC benefits for children no longer living with me.

By providing my electronic signature, I swear that:
I have read, understood, and acknowledged my rights and responsibilities.
The information I have given to WIC is correct to the best of my knowledge.
I have been offered a paper copy of the Participant Rights and Responsibilities.

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Participant Rights and Responsibilities
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, this institution is prohibited from discriminating on the basis of race, color,
national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal orretaliation for prior civil rights activity.
Program information may be made available in languages other than English. Persons withdisabilities who require alternative means of communication to obtain program information (e.g.,
Braille, large print, audiotape, American Sign Language), should contact the responsible state or local
agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY)or contact USDA through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA
Program Discrimination Complaint Form which can be obtained online at:https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter
addressed to USDA. The letter must contain the complainant’s name, address, telephone number,and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant
Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The
completed AD-3027 form or letter must be submitted 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: (833) 256-1665 or (202) 690-7442; or

3email: Program.Intake@usda.gov

This institution is an equal opportunity provider.

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