Fillable Georgia Wic Program - Georgia Department Of Public Health printable pdf download

Georgia WIC Program

Medical Documentation Form for WIC Special Formulas and WIC Foods

Patient’s First & Last Name: ________________________________________ Date of Birth (MM/DD/YY): _____________

Parent/Caregiver’s First & Last Name: ___________________________________________________________________

1. Qualifying Medical Condition(s)

List the SPECIFIC diagnosed or suspected medical condition(s) and the ICD-9 or ICD-10 code(s) justifying the formula/medical

food prescription.

Qualifying diagnosed medical condition(s): __________________________________________________________________

And applicable ICD-9 or ICD-10 code(s): ___________________________________________________________________

Note: WIC approval and provision of prescription formulas and medical foods are based on Georgia WIC Program policies and procedures.

2. Special Formula Requested

Name of formula/medical food requested: ___________________________________________________________________

†

Form:  Powder

 Concentrate

 Ready-to-feed

Prescribed ounces per day: _______________ oz/day*

Special instructions/comments**: __________________________________________________________________________

With Fiber: Yes  No 



If Applicable:

Flavor: ____________________________________

N/A

Planned length of use: ___________ months

WIC prescription renewal is required periodically (every 1-6 months).

Prescribed amount per day is based on reconstituted fluid ounces of the formula product at standard dilution. Instructions on reverse.

**Prematurity: With documentation, premature infants can receive infant formula past one year to account for adjusted age. Medical

documentation will need to be provided at the one year WIC certification.

†

The use of ready-to-feed products requires additional justification for WIC unless ready-to-feed is the only available product form.

3. WIC Foods



Check the box to indicate all WIC foods are allowed or indicate any contraindicated supplemental foods below.



No Supplemental Food Restrictions. (All WIC foods allowed.)

Contraindicated Supplemental Foods – Check the foods that should NOT be issued to the patient.

Infants



Infant Cereal

Baby Food Fruits and Vegetables

(6-11 mos.)



Milk

Beans / Peas

Vegetables / Fruits

Whole Grains (wheat bread,

Children



brown rice, or whole grain

(≥ 12 mos.)

Cheese

Peanut Butter

Juice

tortillas)

& Women



Cereal

Eggs

Canned Fish*

Please describe any other prescribed restrictions or special requests in the “Comments” section below. (Developmental readiness, allergies, tube fed, NPO, etc.)

Comments:

breastfeeding multiple infants.

* Only for exclusively breastfeeding women, women pregnant with multiple fetuses, pregnant women breastfeeding, and women mostly

4. Health Care Provider Information (Please Complete All Boxes.)

Provider’s Signature/*Title:

Provider’s Name (Please Print):

Date:

Original signature required. No stamped signatures or proxy signatures (e.g., by nursing staff) will be accepted.

*Note: The Georgia WIC Program only accepts

prescriptions authorized and signed by the

Medical Office/Clinic Name:

following providers:

Street Address:



Physicians (MD, DO)

City:



Physician Assistants (PA, PA-C)



Zip Code:

Nurse Practitioners (e.g., NP, APRN, CPNP,

Phone Number:

CNP, PNP, CNNP)

Fax Number:

Page 1 of 2

Revised September 2016

Georgia Wic Program - Georgia Department Of Public Health

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