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Exhibit 7.03B

MICHIGAN WIC PROGRAM

Medical Documentation for WIC Formula and Authorized WIC Foods

Infants and Children (through 4 years of age)

WIC Clinic: __________________________________________________ Address: ____________________________________

WIC Contact Person: ________________________________________ Phone: ________________ Fax: ________________

Prescription: Completion of this form is federally required to ensure that the WIC client under your care has a qualifying condition

(medical condition/diagnosis) that requires the use of a WIC formula, medical food and/or changes to their supplemental food

package. A health care provider's prescription will not be accepted as a replacement for this form.

Client’s First & Last Name: ____________________________________________ Birthdate: _______________________

Parent/Caregiver's First & Last Name: _____________________________________________________________________

INFANTS

1. Qualifying medical condition: (refer to back of form):

__________________________________________________________

2. Infant formula requested: _________________________________________________________________

Prescribed amount: □ Maximum allowable or _________ oz per day

Physical Form:

□ Powder

□ Conc

□ RTF

Instructions for preparation and use: _____________________________________________________________________

Medical documentation valid for: □ 1 mo.

□ 2 mo.

□ 3 mo.

□ 4 mo.

□ 5 mo. □ 6 mo. (maximum approval)

3. Supplemental foods allowed: (6-11 mos old)

□ All (maximum allowable)

□ None (issue infant formula only) □

Restriction: (check foods to be omitted)

□ infant cereal

□ infant fruits/vegetables

CHILDREN

1. Qualifying medical condition (refer to back of form): __________________________________________________________

2. WIC formula/ medical food requested: __________________________________________________________________

Prescribed amount: □ Maximum allowable or _________ oz per day

Physical Form:

□ Powder

□ Conc

□ RTF

Special instructions or restrictions: _______________________________________________________________________

Medical documentation valid for: □ 1 mo.

□ 2 mo.

□ 3 mo.

□ 4 mo.

□ 5 mo. □ 6 mo. (maximum approval)

□ Issue whole milk: (Children receiving a medical formula/food who need additional calories may receive whole milk).

3. Cheese Substitution: (With a qualifying medical condition, additional cheese may be substituted for milk).

□ Cheese Prescribed amount per day: □ Maximum allowable □ Other amount (specify) _______________________

4. Soy Beverage Substitution: (With a qualifying medical condition or one of the conditions listed below, soy beverage may be

substituted for milk).

□ Soy Beverage □ Milk protein allergy

□ Severe lactose maldigestion (cannot tolerate lactose free milk)

□ Vegan diet

5. Supplemental foods allowed:

□ All (maximum allowable) □ None (issue medical formula / food only) □ Restriction: (check foods to be omitted)

□ juice

□ breakfast cereal

□ milk

□ cheese

□ legumes / peanut butter

□ eggs

□ fruits and vegetables

□ whole grains

Instructions / Comments: ______________________________________________________________________________

SIGNATURE (Health Care Provider) :

Date:

Printed Name (Health Care Provider):

Medical Office/ Clinic:

Telephone:

Address:

DCH-1326 (rev.03/1/11)

This institution is an equal opportunity provider

Form Dch-1326 - Michigan Wic Program - Infants And Children (Through 4 Years Of Age) Form - Michigan

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