Wic Formula And Medical Nutritional Prescriptions

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WIC FORMULA and MEDICAL NUTRITIONAL PRESCRIPTIONS
All components of this form are required and must be completed by a medical provider to receive Medically Prescribed Formulas
through the WIC program. Personally identifiable information is used to determine WIC services (e.g., certification/enrollment and food
package issuance) and may be disclosed to others only as allowed by state and federal laws.
Patient
Last Name
First Name
Birthdate (mm/dd/yyyy)
Parent/Caregiver
Last Name
First Name
1 . FORMULA PRESCRIPTION
Casein Hydrolysate
Premature & Transitional
Infants (6 months no foods)*
Nutrient Dense
Nutramigen w/Enflora LGG (powder)
Enfamil EnfaCare (powder)
Enfamil Infant (powder)
Nutren Junior with or without fiber
Pregestimil (powder)
Enfamil EnfaCare (RTF)
Enfamil Gentlease (powder)
PediaSure with or without fiber
Alimentum (powder)
Similac NeoSure (powder)
*must be unable to tolerate infant foods
Note: Not allowed for managing body weight
Alimentum (RTF) – for corn allergy only
(see section 3), must have a medical condition
Amino Acid Based
Other Specialized Products
Children requiring Infant formula
Elecare (powder)
Similac PM 60/40 (powder)
Enfamil Infant (powder)
Nutrient Dense -Women Only
Elecare Junior (powder)
Peptamen Junior
Enfamil Gentlease (powder)
Boost with fiber or Boost Plus
with or without fiber (RTF)
E028 Splash (drink box)
Enfamil AR (powder)
Ensure or Ensure Plus
Neocate Infant (powder)
PediaSure Peptide 1.0 cal (RTF)
Enfamil ProSobee (powder)
Neocate Junior (powder)
PurAmino DHA & ARA (powder)
2. FOOD PRESCRIPTION
Infants (0-12 months)
Children (1 -5 years) and Women
Formula and foods*
Formula and foods* beginning at 6 months
Formula ONLY (
)
no foods during duration of this prescription
Formula ONLY (
)
no foods during duration of this prescription
*WIC foods may include the following, based upon program category:
Infants (6-12 months):
Children (1-5 years) & Women:
• Infant Cereal
• Milk
• Cereal
• Peanut Butter
• 100% Juice
• Infant Fruits/Vegetables
• Cheese
• Whole wheat Bread/Buns/Pasta
• Beans
• Fruits/Vegetables
Note: Infant foods can only be issued to Infants 6-12 months
• Brown Rice/ Corn tortillas/ Oatmeal
• Canned Fish (Exclusively Breastfeeding women)
• Eggs
Special Instructions:
(i.e. foods not allowed)
3. DIAGNOSIS, AMOUNT, DURATION
Medical Diagnosis Justifying Formula:
Note: WIC Federal Regulations do n ot allow the follow ing conditions for issuance of medical formulas: managing body weight, growth concerns,
unconfirmed allergies, lactose intolerance, or intolerance symptoms. Please specify the underlying medical condition(s).
up to 2 years
Cerebral Palsy
Developmental Delay
Prematurity (
)
Tube Fed NPO or Pleasure Feeds
Cleft Lip/Palate
Eosinophilic GI Disorders
Hyperemesis Gravidarum
Tube Fed with formula / foods (complete # 2)
Congenital Heart Disease
Gastroesophageal Reflux
Confirmed Allergy (specify):
Other Medical Diagnosis (specify):
Cystic Fibrosis
Intestinal Malabsorption
Prescribed amount:
Maximum amount WIC provides
OR
Ounces per day
OR
Cans per day
Duration:
1 month
2 months
3 months
4 months
5 months
6 months (maximum duration)
Health Care Provider/WIC Clinic Comments:
4. HEALTH CARE PROVIDER’S SIGNATURE, LOCATION, DATE PRESCRIBED
Health Care Provider’s Signature
Date Signed:
(Physician, Physician Assistant or Advanced Practice Nurse Practitioner signature is required for prescriptions of the above formulas or medical foods.)
Printed Name of Health Care Provider
Medical Office/Clinic
Address
Telephone
This institution is an equal opportunity provider.
July 1, 2016

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