Form Adph-Wic-111a - Alabama Wic Infant Formula Prescription With Instructions (Page 2 of 2) in pdf

Form Adph-Wic-111a - Alabama Wic Infant Formula Prescription With Instructions Page 2

Alabama WIC Infant Formula Prescription (ADPH-WIC-111a)

Instructions for Completion of Form

Important

Only this form will be accepted by WIC clinics for special formula requests

Date: Enter date form is being completed.

Infant s Name: Enter name of the infant requiring the non-contract formula.

Date of Birth: Enter the infant s date of birth.

ICD-9 Code and/or Medical Diagnosis: Document the medical diagnosis and/or the

corresponding ICD-9 code. The prescription may be accepted if either the medical diagnosis or

the ICD-9 code is written. However, the medical diagnosis and/or the ICD-9 code must be a

nutrition related medical diagnosis/ICD-9 code.

Formula Prescribed: Enter the name of the special medical formula prescribed for the infant.

Must indicate Amount per Day: Check the amount of formula allowed by WIC according to

infant s age or check if lesser amount is needed and write amount.

Intended length of use: Check the number of months formula is needed. Note that the infant s

need for the special formula must be re-evaluated by the physician at six (6) months of age.

Supplemental Foods: Check if infant is not to receive infant cereal and/or infant vegetables and

fruits at 6 months of age. Check if infant is medically fragile and unable to consume solid foods

at 6 months of age.

Signature of Health Care Provider: The physician s signature must be entered.

Provider s Name, printed: PRINT physician s name.

Phone: Enter the physician s phone number.

Fax: Enter the physician s fax number.

WIC Clinic Use Only: Information is required to be completed.

CHR #: Enter the infant s CHR number.

Date Received: Enter the date the clinic receives the prescription form.

Approved by: Enter the name of the person approving the acceptance of the prescription.

Form Adph-Wic-111a - Alabama Wic Infant Formula Prescription With Instructions Page 2