Request For Wic Therapeutic Products And Supplemental Foods Form - Tennessee Department Of Health

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TENNESSEE DEPARTMENT OF HEALTH
REQUEST FOR WIC THERAPEUTIC PRODUCTS AND SUPPLEMENTAL FOODS
MUST BE COMPLETED BY HEALTHCARE PROVIDER
Patient’s Name: _________________________________________ Date of Birth: ___________________
Formula Requested: ______________________ Dilution Strength (if >standard for product) __________
Amount per 24 hours:
maximum allowed (approx. 26 oz/day) or _____ day Tube Fed:
Y
N
Requested length of issuance:
1mo 2mo
3 mo
4mo
5mo
6 mo
Most Recent Date of Measures: ___________ Weight: ___________ Height/Length: ________________
Nutrition Related WIC Qualifying Condition: ________________________________________________
If food allergy must specify the confirmed allergic disorder:
Food protein induced enterocolitis
Eosinophilic gastroenteritis
Gastrointestinal anaphylaxis
Food protein induced proctocolitis
Eosinophilic esophagitis
Atopic disease
Food protein enteropathy, celiac
Acute or chronic urticaria & angiodema
Clinical Findings, Laboratory Results, Diagnostic Evidence of Need: ______________________________
_____________________________________________________________________________________
Supplemental WIC foods listed below will be issued in addition to the formula /nutritional product
requested. Please indicate any food restrictions or provisions for the patient.
Infants (6-11 months)
Children & Women
DO NOT GIVE:
DO NOT GIVE:
Milk
Peanut Butter
Vegetables/Fruits
Infant Cereal
Cheese
Dried Beans/Peas
Cereal
Infant Vegetables/Fruits
Juice
Whole Grain Products
Canned Fish (Breastfeeding
Eggs
Soy Beverage or Tofu
Women Only)
DO PROVIDE:
Higher Fat Milk:
2%
Whole
Pureed (Infant Food) Vegetables/Fruits
Prescribing Health Care Provider (HCP):
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
Contact Phone: __________________________ Fax: __________________________________________
Signature (including credentials) ____________________________ Date of Request: _______________
REQUEST IS SUBJECT TO TN WIC APPROVAL AND PROVISION BASED ON PROGRAM REGULATION AND POLICY
WIC Use Only _________________________________________________________________________
PH-4077 (Rev 10/14)
RDA 150

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