Wic Eligible Formula And Nutritionals Food Listing Page 2
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2Wyoming WIC Program Medical Documentation
WIC Agency:
Prescription subject to WIC approval based on program policy and procedure.
WIC Fax Number:
This is the only Medical Documentation form accepted by the Wyoming WIC Program.
WIC ID:
Patient’s Name:
Birth Date (MM/DD/YY):
Parent/Guardian’s Name:
QUALIFIYING MEDICAL CONDITION(S)
ICD-10 code is required, as well as, the underlying condition.
Personal Preference, Formula Intolerance, Fussiness, Gas, Constipation, Spitting Up, or Colic are not acceptable diagnoses.
Regardless of diagnosis, non-contract standard formulas cannot be issued to WIC participants in place of the WY WIC contract formulas.
√
ICD-10
Description
√
ICD-10
Description
D50
Iron deficiency anemia
P07.0
Extremely low birth weight newborn
D80
Immunodeficiency with pred. antibody defects
P07.2
Extreme immaturity of newborn
E08-E13
Diabetes Mellitus
P07.3
Preterm (premature) newborn
E70.0
Phenylketonuria (PKU)
P77
Necrotizing enterocolitis
E73.9
Lactose Intolerance, unspecified
P78.83
Newborn esophageal reflux
E74.21
Galactosemia
P92.6
Failure to thrive in newborn
E849
Cystic Fibrosis
Q35
Cleft palate
G71.0
Muscular dystrophy
Q36
Cleft lip
G80
Cerebral Palsy
R62.51
Failure to thrive (child)
T78.0
Anaphylactic reaction due to food: specify food
K50
Crohn’s disease
K90.0
Celiac disease
Z91.011
Milk allergy
P05.0
Newborn light for gestational age
P05.1
Newborn small for gestational age
Other Medical Diagnosis (please specify):
NON-CONTRACT FORMULA/NUTRITIONALS
Formula Requested:
Flavor if Applicable:
With Fiber: □ Yes □ No □ N/A
Physical Form: □ Powder □ Concentrate □ RTF: _______________________________________________________________________
(The use of RTF products requires additional justification unless RTF is the only available form)
Daily Amount Requested:
Requested Approval Length
:
(six months will be issued if nothing is marked)
_______ Maximum Allowed (per Federal Regulation)
□ 1 Month
□ 4 Months
_______ Ounces/Day
□ 2 Months
□ 5 Months
_______ Cans/Day
□ 3 Months
□ 6 Months
DIET RESTRICTIONS
□ No WIC foods; provide formula only.
Check foods to be omitted (all benefits will be provided if nothing is marked):
WIC food for infants (6 to 12 months):
WIC food for children (1 to 5 years of age) and women:
□ Infant Cereal
□ Milk
□ Cheese □ Peanut Butter □ Legumes □ Breakfast Cereals □ Eggs
□ Infant Fruits & Vegetables
□ Fruits and Vegetables □ Whole Grains □ Juice
□ Canned Fish (For Women Only)
FOOD SUBSTITUTIONS
(Allowed only with appropriate medical condition. Issuance for personal preference is NOT allowed.)
□ Whole Milk: Issue whole milk for a child over 2 or a woman. Only participants receiving non-contract formula/nutritionals with a
qualifying medical condition can be issued whole milk.
HEALTH CARE PROVIDER INFORMATION
Provider’s Signature:
Date:
Provider’s Name:
Medical Office Name and Address:
Phone:
Fax:
This institution is an equal opportunity provider.
Revised 6/6/2016
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