Georgia Wic Program

Download a blank fillable Georgia Wic Program in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Georgia Wic Program with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

1
Georgia WIC Program
Medical Documentation Form for WIC Special Formulas and WIC Foods
Patient’s First & Last Name: ________________________________________ Date of Birth (MM/DD/YY): ____/____/____
Parent/Caregiver’s First & Last Name: ___________________________________________________________________
1. Qualifying Medical Condition(s)
List the SPECIFIC diagnosed or suspected medical condition(s) and the ICD-9 or ICD-10 code(s) justifying the formula/medical
food prescription.
Qualifying diagnosed medical condition(s): __________________________________________________________________
And applicable ICD-9 or ICD-10 code(s): ___________________________________________________________________
Note: WIC approval and provision of prescription formulas and medical foods are based on Georgia WIC Program policies and procedures.
2. Special Formula Requested
Name of formula/medical food requested: ___________________________________________________________________
Prescribed ounces per day: _______________ oz/day*
Form:  Powder
 Concentrate
 Ready-to-feed
Special instructions/comments**: __________________________________________________________________________
Flavor: ____________________________________
With Fiber: Yes  No 
N/A
If Applicable:
Planned length of use: ___________ months
WIC prescription renewal is required periodically (every 1-6 months).
*
Prescribed amount per day is based on reconstituted fluid ounces of the formula product at standard dilution. Instructions on reverse.
**Prematurity: **: With documentation, premature infants can receive infant formula past one year to account for adjusted age. Medical
documentation will need to be provided at the one year WIC certification.
The use of ready-to-feed products requires additional justification for WIC unless ready-to-feed is the only available product form.
3. WIC Foods
Please complete section A or section B below. The patient may receive the supplemental foods – appropriate to his or her
WIC participant category – listed below in addition to the approved special formula.
A.
No Supplemental Food Restrictions: ___________ (provider initials)
If there are
prescribed food restrictions, please initial the “No Supplemental Food Restrictions” line above.
no
If there are prescribed food restrictions due to the patient’s medical condition(s):
B.
In the “Contraindicated Supplemental Foods” column, please check (
) any supplemental foods that
be issued
cannot
due to the patient’s medical condition(s). Please describe any other prescribed restrictions or special requests in the
“Comments” section below. (Developmental readiness, allergies, tube fed, NPO, etc.)
WIC Category
NOT
Contraindicated Supplemental Foods – Check the foods that should
be issued to the patient.
Infants
Infant Cereal
Baby Food Fruits and Vegetables
(6-11 mos.)
Milk
Beans / Peas
Vegetables / Fruits
Whole Grains (wheat bread,
Children (≥ 12 mos.)
rice, or whole grain tortillas)
Cheese
Peanut Butter
Juice
& Women
Cereal
Eggs
Canned Fish*
Comments:
* Only for exclusively breastfeeding women, women pregnant with multiple fetuses, and women mostly breastfeeding multiple infants.
4. Health Care Provider Information (Please Complete All Boxes.)
Provider’s Signature/Credentials:
*Title:
/
/
Provider’s Name (Please Print):
Date:
Original signature required. No stamped signatures or
proxy signatures (e.g., by nursing staff) will be accepted.
Medical Office/Clinic Name:
*Note: The Georgia WIC Program only accepts
Street Address:
prescriptions authorized and signed by the following
City:
providers:
Zip Code:
Physicians (MD, DO)
Phone Number:
Physician Assistants (PA, PA-C)
Fax Number:
Nurse Practitioners (e.g., NP, APRN, CPNP,
CNP, PNP, CNNP)
Page 1 of 2
Revised June 2012

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2