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LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

OFFICE OF PUBLIC HEALTH NUTRITION SERVICES

Louisiana Women, Infant and Children (WIC) Special Supplemental Nutrition Program

Medical Documentation for WIC Medical Formula and Approved WIC Foods for Infants, Children and Women

This request must be completed with the signature of the physician or a licensed healthcare professional with prescriptive authority

under Louisiana law. The signed and dated request should be less than 60 days old when received by the clinic staff. The completed

. The

form can be submitted by fax or hand delivered by the provider/participant/caregiver to the clinic

prescription is subject to WIC

approval and provision based on Program policy and procedure. The Louisiana WIC Program requires that a written request for

the approval of these formulas be submitted every 6 months. The Louisiana WIC Formulary is the only reference source of WIC

approved special formulas and is located at

Patient’s name: _______________________________________________________

Date of Birth ____________________

(Please Print)

Last

First

(MM/DD/YY)

Weight_______ Length/Height ______

Hgb _____ Hct______ Date of measurements/Lab ________

Weeks gestation_________

Parent/Caregiver name (First and Last): __________________________________________________________________________

Medical Diagnosis/Qualifying Condition: (Justifies medical need for formula/food)

Include ICD-9 Code

________________________________________________________

________________

________________________________________________________

________________

________________________________________________________

________________

 Maximum Allowed

 _____________ Per Day

Name of WIC formula/medical food requested: ___________________

Medical documentation valid for: ___ Months

Special Instructions: ______________________________

(Not to exceed 6 months)

__________________________________________________________________________________________________________

WIC Supplemental Food: In addition to the medical formula/food, supplemental food appropriate to the WIC participant’s category will

be provided. Louisiana WIC routinely provides 2% or less reduced fat milk to children > 2 years. Please indicate below any

supplemental food that would be contraindicated and/or require special instructions specific to the participant’s medical diagnosis.

(See reverse side for a listing of formula and WIC supplemental foods).

 WIC supplemental food is contraindicated

 Provide medical formula only

 Provide all appropriate WIC supplemental food for WIC participant category

WIC Participant Category

WIC Supplemental Food Restrictions

Comments

Infants (greater than 6

months)

Children (13 - 60 months)

and Women

Soy Beverage (for children 13-60 months) Indicate the qualifying condition that justifies the need for soy beverage as a milk

substitute. (personal preference is not a qualifying condition).

 Milk Allergy

 Severe Lactose Intolerance

 Vegan Diet

 Other: ________________________________________

Health Care Provider Information

__________________________

__________

(

)_____________________________________

Signature (MD, PA, NP,)

Date

Telephone Number

WIC Staff Use Only

If approved – for how long? _____________

WIC Participant ID Number __________________

Approved ___Yes ___ No

Comments_____________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Signature________________________________________________________

Date________________________

(WIC Licensed/Registered Dietitian/Nutritionist)

WIC – 48

Rev 5/09

Form Wic-48 - Louisiana Women, Infant And Children (Wic) Special Supplemental Nutrition Program Form - Louisiana Department Of Health And Hospitals

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