Michigan Wic Special Formula/food Request
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1MICHIGAN WIC SPECIAL FORMULA/FOOD REQUEST
Michigan Department of Health and Human Services
Client Name
Date of Birth
Parent/Guardian Name
Please specify the underlying qualifying condition below. Conditions such as rash, non-specific intolerance, underweight, fussiness,
colic, spitting-up, vomiting, gas and constipation will NOT be considered indications for a special formula.
1.
QUALIFYING MEDICAL CONDITION(S):
Premature birth < 37 weeks gestation
Failure to thrive
Severe food allergies (specify)
Immune system disorder (specify)
Metabolic disorder/inborn errors of metabolism (specify)
Medical condition that impairs nutrition status (specify)
Gastrointestinal disorder/malabsorption syndromes (specify)
2.
FORMULA:
Select Amount Requested:
Ounces/day or
Maximum Allowable*
*Up to the WIC maximum allowable may be provided. Maximum allowable may not meet patient’s full need.
A list of Michigan Authorized Formulas is available at: click on Medical Providers
3.
SUPPLEMENTAL WIC FOODS: (CHECK ONE; MUST BE COMPLETED FOR ALL FORMULA REQUESTS)
All (issue all allowed age appropriate WIC Foods starting at six months)
Restriction (check foods to be OMITTED):
Infant (6-12 months)
Child (1-5 years) and Woman
Special Instructions/Comments:
All (issue formula only)
All (issue formula only)
Infant cereal
Milk
Infant fruits/vegetables
Yogurt
Cheese
Eggs
Legumes
Peanut butter
Breakfast cereal
Bread, rice, tortilla, oatmeal, pasta
Fresh fruits/vegetables
100% fruit/vegetable juice
Canned fish (women only)
4.
MILK SUBSTITUTIONS (optional): Medical Reason for Milkfat Change:
2% milk (in place of ≤ 1% milkfat, woman/child ≥ 2 years; or whole milk, child 12-23 months). Honored only if medically indicated.
Whole milk (in place of ≤1% milkfat, woman/child ≥ 2 years). Honored only if medically indicated formula prescribed above.
Soy Beverage in place of milk for child:
Milk allergy
Lactose intolerance
Vegetarian/Vegan diet
Cultural practice
Other
5.
DURATION:
1 month
2 months
3 months
4 months
5 months
6 months (maximum approval)
Medical Provider Name
WIC Use Only
Client # (Optional)
Address
Approved Through (Optional)
Phone Number
Fax
Reason (if denied)
Signature
Date
Signature (if denied)
Date
WIC CLINIC:
Phone:
Fax:
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age,
national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
This institution is an equal opportunity provider.
DCH-1326 (Rev. 9-16) Previous edition obsolete.
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Parent category: Medical