Fillable Wic Medical Documentation Form (Page 2 of 2) in pdf

Instructions & Resources for Use of This Form:

This form is intended for use as…

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A medical data referral form for infants, children and women for the Georgia WIC Program, and/or

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To authorize special food substitutions for children and women enrolled in the Georgia WIC Program.

To prescribe a special formula or medical food for an infant, child or woman, please refer to Georgia WIC Form #1

(Medical Documentation Form for WIC Special Formulas and WIC Foods).

To Provide Referral Information Only:

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Enter the patient’s full name, date of birth, and (for infants/children) the parent/caregiver’s name at the top of the form.

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Complete the “Medical Office/Clinic” contact information.

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Complete the applicable information under “Referral Data.”

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Sign and date the form under “Referral Data.”

To Authorize a Special Food Substitution For a Child or Woman:

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Enter the patient’s full name, date of birth, and (for infants/children) the parent/caregiver’s name at the top of the form.

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Complete the “Medical Office/Clinic” contact information.

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Provide all of the information requested under the applicable heading (“CHILDREN” or “WOMEN”) to authorize the

special food substitution. Please remember to sign your name and include your credentials, today’s date, and your

printed name. Incomplete forms will delay processing of the food substitution prescribed and will require WIC clinic

staff to contact your office for additional documentation.

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Include any applicable referral information you would like to provide to the WIC clinic under “Referral Data.” The

provision of referral data is not mandatory in order to authorize special food substitutions for a WIC client.

In accordance with federal regulations, the Georgia WIC Program only accepts medical documentation/prescriptions

signed by health care providers who have prescriptive authority based on the laws of the state of Georgia. Therefore,

physicians (MD, DO), physician assistants (PA, PA-C), and nurse practitioners (e.g., NP, APRN, CPNP, CNP, PNP,

CNNP) are the only providers authorized to sign medical documentation/prescriptions for Georgia WIC use.

If you have questions or need additional clarification when completing this form, please contact the local WIC agency

where your patient is receiving WIC benefits. A directory containing Georgia WIC clinic contact information is available at

Georgia WIC Program Policies:

Prescribed Quantity of Supplemental Foods: Exact amounts of authorized food substitutions will be determined by

Georgia WIC Program staff. The quantity of the supplement foods provided by the Georgia WIC Program is subject to the

maximum allowable quantities determined by federal regulations and outlined in Georgia WIC Program policies.

WIC is a supplemental program. Patients are responsible for acquiring any additional prescribed quantities of foods that

exceed what is eligible for provision through WIC.

Medical Justification for Food Substitutions: Federal regulations require medical documentation of a qualifying

medical condition for issuance of the special milk substitutions described below:

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The issuance of any quantity of soy milk or tofu to children (ages 1-5 years old)

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The issuance of more than one (1) pound of cheese per month to children (ages 1-5 years old)

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The issuance of more than one (1) or three (3) pounds of cheese per month to women*

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The issuance of more than four (4) or six (6) pounds of tofu per month to women*

*Note: The exact quantity depends upon a woman’s Georgia WIC Program participant category and her infant feeding method.

Milk: In accordance with federal regulations, younger children (ages 12-23 months) will receive whole milk while women

and older children (ages ≥ 24 months) will receive low-fat milk from the Georgia WIC Program. Cow’s milk and milk

substitutes (e.g., soy milk, goat milk, tofu, cheese) cannot be issued to infants (ages birth – 11 months) by the Georgia

WIC Program, even with a prescription.

Planned Length of Use: Please specify the expected length of time the child or woman will need to be prescribed the

special food substitutions. The Georgia WIC Program requires renewal of medical documentation for special food

substitutions at every WIC certification/recertification (approximately every 6 months).

We appreciate your cooperation and partnership in serving the Georgia WIC population.

In accordance with Federal Law and U .S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color,

national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW,

Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). I ndividuals who are hearing impaired or have speech disabilities may contact

USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.

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