Medical Documentation For Wic Formula And Approved Wic Foods For Women, Infants And Children
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2Medical Documentation for WIC Formula and
NEW YORK STATE DEPARTMENT OF HEALTH
Approved WIC Foods for Women, Infants and Children
Division of Nutrition
WIC
WIC Stamp
Instructions: Providers, please complete sections A-D for ALL WIC participants to request
formula and supplemental foods. The provision of formula/food is subject to WIC policies
and procedures. (Detailed instructions and resources on back)
A. PATIENT INFORMATION
/
/
Patient’s Name:
Date of Birth:
B. FORMULA
☐
☐
☐
Formula Requested:
Length of Use:
1 month
6 months
months
☐
☐
3 months
12 months
Prescribed Amount:
ounces/day
Special Instructions/Comments:
WIC Qualifying Medical Conditions:
☐
☐
☐
Premature Birth
Metabolic Disorders
Failure to Thrive
Note: These non-specific symptoms/
conditions are not acceptable: dermatitis,
(Must meet at least one of the criteria on back)
☐
☐
☐
formula/food intolerance, fussiness, gas,
Severe Food Allergies
Low Birth Weight
Immune System Disorders
spitting up, constipation, diarrhea, vomiting,
☐
☐
☐
colic, or to enhance or manage body weight
without an underlying medical condition.
GI Disorders
Malabsorption Syndromes
Other (Specify):
C. WIC SUPPLEMENTAL FOODS (WIC does not provide supplemental foods to infants < 6 months old)
☐
☐
YES
NO I authorize qualified WIC staff to determine supplemental foods and amounts based on the patient’s medical condition.
If NO, select ONE of the following options:
☐
No food restrictions; provide full amount of age-appropriate foods
☐
Infant <6 months; provide formula only
☐
Patient requires food restrictions based on medical condition (provider MUST complete the following):
☐
≥ 6 months cannot tolerate solid food: provide formula only
☐
≥ 12 months cannot tolerate solid food: provide jarred baby fruits & vegetables in lieu of fruit & vegetable voucher
☐
OMIT the following food(s) based on medical condition:
☐
☐
☐
Infant Cereal
Baby Food Fruits/Vegetables
Fresh Fruits/Vegetables (9-11 months)
Infants (6-11 months):
☐
☐
☐
☐
☐
Children (≥ 12 months) & Women:
Peanut Butter
Milk
Whole Grains
Cheese
Yogurt
☐
☐
☐
☐
☐
Cereal
Canned Fish
Vegetables/Fruits
Beans
Juice
Provider Stamp
D. HEALTH CARE PROVIDER INFORMATION (Contact information may be printed or stamped and must be legible)
Provider’s Signature
Date
Street
City, State, Zip Code
Provider’s Printed Name
Telephone Number
Fax Number
E. RELEASE OF INFORMATION
I authorize the above health care provider and NYS WIC agency staff to disclose/discuss information regarding feeding needs. This permission is
good for the length of this certification. I understand that I may cancel this permission at any time by request to my health care provider and WIC.
This release is not a condition of WIC eligibility.
Participant/Parent/Caregiver Signature
Date
Printed Name
F. WIC STAFF USE ONLY (WIC staff must complete section in its entirety and note comments/actions)
Consent on file at WIC
Check box next to question if the answer is yes:
Approved
Disapproved
Pending
Pending Date & Initial
Acceptable qualifying condition indicated?
Signature:
Formula consistent with qualifying condition?
Amount and length appropriate?
Printed Name:
Date:
Med Doc Foods note written?
Comments:
WIC ID #
DOH-4456 (5/15) Page 1 of 2
This institution is an equal opportunity provider and employer.
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