Maryland Wic Program Medical Documentation Form
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2Maryland WIC Program Medical Documentation Form
This form is federally required to ensure your patient has a medical diagnosis that requires a
formula/medical food or changes to the WIC food package.
Sections 1 - 4 MUST be completed.
All requests are subject to WIC approval.
1
Patient Name: _________________________
Patient DOB: ____________________
Parent/Guardian: ______________________
Patient EDD: ____________________
Medical
Weight:
Length/height:
Hgb:
data:
Hct:
Date measured:
Date measured:
Date measured:
2
Medical Diagnosis: (Required) _________________________________________________
Non-specific symptoms such as intolerance, fussiness, colic, spitting up, gas, and constipation will NOT be considered
indications for a special formula. NOTE: Appropriate medical documentation is also required when requesting soy
beverage or tofu for a child ≥1 year of age.
Current symptom(s):
chronic diarrhea
persistent respiratory condition
chronic/persistent emesis
anaphylactic reaction
persistent rash
other_______________________________________
:_________________________________________
WIC products requested
A request for formula for an infant will be considered only when Similac Advance or Similac Sensitive for Fussiness & Gas AND
Enfamil Prosobee are inappropriate due to medical diagnosis. Note: WIC does not provide non-contract milk- or soy-based
standard infant formulas such as Enfamil Premium Newborn, Enfamil Premium Infant, Similac Isomil Soy, or Good
Start products. Specialized formulas may be provided, when appropriate, regardless of manufacturer.
: ________________________________________________
Amount prescribed per day
:
Requested duration
(Reauthorization may be required for a duration beyond 6 months.)
1 month
2 months
3 months
6 months
Other__________________________
3
WIC Food Restrictions/Requests (
Check all that apply. This section must be completed.)
Request WIC professional to determine food recommendations.
No food restrictions.
Request whole milk for child (≥ 2 years of age) or women for growth/weight-related diagnosis.
Request soy beverage and/or tofu for child (≥ 1 year of age) to replace milk and/or cheese.
Issue formula or medical food only. Do not issue other WIC foods.
Do not issue the WIC foods checked below:
Woman or Child WIC Foods
DO NOT GIVE
Infant WIC Foods*
DO NOT GIVE
Milk
Infant cereal
Cheese
Infant vegetables/fruit
Eggs
Beans
*6 to 12 months of age
Peanut butter (≥ age 2)
Cereal
Whole grain bread, rice, tortillas**
Vegetables & fruit
Comments:
Fruit juice
Canned fish**
**See WIC Foods List for details
Provider name ___________________________________
WIC use only: Date received ______________
4
Request approved
Request denied
Provider phone # _________________________________
CPA
Provider signature _______________________________
Signature _______________________Date________
(MD/DO/CNM/CNP/PA with prescriptive authority signature required.)
Today’s date____________________________________
10/01/12
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Parent category: Medical