Form Adph-Wic-111a - Alabama Wic Infant Formula Prescription With Instructions printable pdf download

Form Adph-Wic-111a - Alabama Wic Infant Formula Prescription With Instructions

Alabama WIC Infant Formula Prescription

Prescription is subject to WIC Approval based on Program Policy and Procedure

Date________________

Infant s Name _____________________________ Date of Birth___________

ICD-9 Code and/or Medical Diagnosis_________________________________

Not WIC Approved: Colic, Spitting up, Fussiness, Constipation or Formula Intolerance

Formula Prescribed _________________________________________________

Must Indicate Amount Per Day

Maximum ounces allowed by WIC for Fully Formula Fed Infant

0-3 mos - 26 fluid oz/day

4-5 mos - 29 fluid oz/day

6-12 mos - 20 fluid oz /day

Infant needs lesser amount; amount is ________________oz per day

Intended length of use

6 months

At 6 months of age a new prescription is required. Exception: In disease/chronic diseases

such as but not limited to, inborn errors of metabolism, galactosemia, celiac disease, and

cystic fibrosis, the initial prescription is sufficient.

If the prescription is not renewed, a standard contract formula will be issued.*

- Re-evaluating the infant s need for a special formula past 6 months of age ensures that WIC

funds are utilized in the most cost effective way.

*Notice: The standard contract formulas are: Similac Advance EarlyShield, Similac Isomil Advance, and

Similac Sensitive. Other milk based, soy based and milk based lactose free formulas are not WIC approved.

Supplemental Foods

At 6 months of age WIC will issue the following foods unless otherwise indicated.

Infant cereal

Not Allowed

Infant vegetables and fruits

Not Allowed

This infant (6-12 months of age) is medically fragile, and unable to consume

solid food. I authorize additional formula (total 29 oz/day) to meet nutritional

needs.

Signature of Health Care Provider_________________________________________

Provider s Name ( Please print)____________________________________________

Phone (___)________________________ Fax (___)___________________________

If you have questions please call your local WIC clinic.

WIC Clinic Use Only

CHR# __________________

Date Received __________

Approved by __________________

ADPH-WIC-111a-7-09

Form Adph-Wic-111a - Alabama Wic Infant Formula Prescription With Instructions