Wic-11 - Medical Documentation For Wic Formula And Approved Wic Foods For Infants, Children And Women
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1
2New Jersey Department of Health
WIC Services
MEDICAL DOCUMENTATION FOR WIC FORMULA AND
APPROVED WIC FOODS FOR INFANTS, CHILDREN AND WOMEN
WIC Clinic
Phone
Fax
Please complete entire form. Fax the completed form to the WIC clinic or have your patient return the
document to the WIC Clinic. Thank you!
PLEASE NOTE: It is the responsibility of the health care provider to provide close medical oversight and instructions to
participants issued exempt infant formula, WIC-eligible Nutritionals and/or supplemental foods that require medical
documentation. This responsibility cannot be assumed by personnel at the WIC State or local agency.
Re-authorization is required every three months.
No authorization is necessary for Enfamil Infant, Enfamil Gentlease and Prosobee. Documentation for Enfamil AR
is requested, but not required.
Patient Name (First and Last)
Current Height/Length:
Date of Birth
Current Weight:
Parent/Caregiver Name (First and Last)
Date
1.
Formula Requested:
Amount Requested:
Maximum Allowable
OR
ounces/day (if formula)
Physical Form:
Powder
Concentrate
Intended Length of Use:
1 Month
2 Months
3 Months
2.
Qualifying Condition(s) (Justifies the medical need.)
(Complete and submit Page 2 with this form.)
3.
Can patient receive supplemental (or other WIC) foods in addition to formula or medical food?
Yes
No
(If Yes, please check the foods below that your patient CAN / IS eating.)
Infants (6-11 months only):
Infant Cereal
Infant Vegetable or Fruit
Children and Women:
Juice
Breakfast Cereal
Whole Wheat Bread or Other Whole Grains
Eggs
Vegetables and Fruits
Milk or Milk Substitutes
Legumes
Canned Fish*
Peanut Butter
Reasons/Instructions/Comments:
*Fully breastfeeding women, women partially breastfeeding multiple infants from the same pregnancy, women pregnant with
multiple infants, and pregnant women who are mostly breastfeeding an infant are the only WIC participant categories eligible
to receive these foods.
Health Care Provider Name (Print)
MD
DO
APN
PA-C
Medical Office/Clinic
Telephone Number
Medical Office/Clinic Address
Fax Number
Health Care Provider Signature
Date
WIC OFFICE USE ONLY:
Reviewed by CPA Name:
Date:
If required: MS and/or RD CPA Name:
Approved
# of months: _________
Disapproved
WIC-11
This institution is an equal opportunity provider.
APR 16
Page 1 of 2 Pages.
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