Form Wic-48 - Louisiana Women, Infant And Children (Wic) Special Supplemental Nutrition Program Form - Louisiana Department Of Health And Hospitals Page 3
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3LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS
OFFICE OF PUBLIC HEALTH NUTRITION SERVICES
Louisiana Women, Infant and Children (WIC) Special Supplemental Nutrition Program
Instructions for using the WIC Medical Documentation for WIC Medical Formula and
Approved Food for Infants, Children and Women Form
The WIC-48 form is used to communicate with the Louisiana WIC Program by a licensed health
care professional authorized to write medical prescriptions under state law.
The participant must complete the WIC certification process before the formula is approved.
The licensed health care professional (i.e., MD, PA, NP) will complete the following sections on the
form:
Patient’s name
1.
Date of birth
Weight, length/height
Date of measurements
Hemotocrit
Hemoglobin
Weeks gestation
2. Name of formula requested, length of time the formula is needed and any comments or
special instructions
3. Medical reason or qualifying diagnosis, ICD-9 Code
4. Complete all other appropriate sections of the form
5. See reverse side of the WIC - 48 form for a listing of allowed formula and food for
all WIC Participant Categories
6. Signature, date and telephone number of the licensed health care provider
The signed and dated request should not be greater than 60 days old when received by the clinic
staff.
No stamped signatures. Electronic signatures are allowed.
The completed form can be submitted by e-mail (electronic signature) fax or hand delivered by the
provider/participant/caregiver to the clinic staff.
The WIC Nutritionist will review the request and complete the “WIC Staff Use Only” section of the
form:
Approved, check yes or no
How long approved (number of days/months, up to six months)
Comments
Signature and date signed
The participant and Medical Provider will be advised of the disapproval by the appropriate clinic
staff.
A copy of this form will be maintained in the participant’s medical record.
WIC – 48
Rev 5/09
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