Georgia Wic Program - Georgia Department Of Public Health

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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: ____________________________________
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.
Infant Cereal
Baby Food Fruits and Vegetables
(6-11 mos.)
Beans / Peas
Vegetables / Fruits
Whole Grains (wheat bread,
brown rice, or whole grain
(≥ 12 mos.)
Peanut Butter
& Women
Canned Fish*
Please describe any other prescribed restrictions or special requests in the “Comments” section below. (Developmental readiness, allergies, tube fed, NPO, etc.)
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):
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)
Physician Assistants (PA, PA-C)
Zip Code:
Nurse Practitioners (e.g., NP, APRN, CPNP,
Phone Number:
Fax Number:
Page 1 of 2
Revised September 2016


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