Massachusetts Wic Nutrition Program Request For Special Formula And Food
ADVERTISEMENT
1MASSACHUSETTS WIC NUTRITION PROGRAM
REQUEST FOR SPECIAL FORMULA AND FOOD
Participant’s Name: _______________________________________
Date of Birth (DOB): ____ /____ /________
Guardian’s Name: ________________________________________
Weeks Gestation (for premature infants): ________
Formula or medical food requested: _____________________________________________________________________
Prescribed oz per day: _______ ad lib or _______ oz per day
Powder
Concentrate
RTF (restrictions apply)
Intended length of use: ______ months
Caloric density (if applicable): ______________
Comments/Instructions: ___________________________________________________________________________________________
Soy-based calcium sources are available for participants who follow strict vegan diets or have a milk protein
allergy. Foods requested:
Tofu
Soy-based beverage
REQUIRED: Please check qualifying medical condition(s)/ICD code(s)
Allergy, Food: ______________ (693.1)
Diabetes Mellitus Type I (250.01)
Lactose Intolerance (271.3)
Autoimmune Disorder (279.4)
Diseases of the Digestive System
Malnutrition (263.9)
Anomaly, Respiratory (748.9)
(520-579); specify: _____________
Neuromuscular Disorder (358.9)
Anomaly, GI (751.9)
Endocrine, Nutritional & Metabolic
Pregnancy, Multiple Gestation (651)
Conditions Originating in the Perinatal
Diseases, and Immunity Disorders
Prematurity (765.1)
Period (760-779); specify:____________
(240—279); specify:_____________
Other: specify nutrition-related condition
Congenital Heart Disease (746.9)
FTT/Inadequate Growth (783.4)
ICD code:
and
Delay, Developmental (783.4)
Immunodeficiency (279.3)
_______________________________
Additional WIC supplemental foods available (Please check foods that are not allowed based on medical diagnosis.)
Milk:
fat free/lowfat
whole
Eggs
Fruits/vegetables
Cheese
Legumes (beans/peas)
Canned fish (for fully breastfeeding women)
Juice
Peanut butter
Infant fruits/vegetables
Cereal
Whole wheat bread/whole grains
Physician/Physician Assistant/Nurse Practitioner Signature: ________________________________________ Date: ________
Provider Printed Name: ____________________________________________________________ Phone: _______________________
Provider Stamp or Address:
The Massachusetts WIC Nutrition Program strongly endorses breastfeeding as the optimal way to feed most infants. For infants that do
-
consume formula, Massachusetts WIC standard contract formulas are Enfamil PREMIUM Infant and Enfamil ProSobee (soy).
WIC participants who carry MassHealth insurance will receive metabolic/special formulas through MassHealth upon prior authorization.
-
To obtain authorization, contact MassHealth or the member’s Managed Care Organization. MassHealth members requiring Enfamil
Gentlease and Enfamil A.R. will receive these formulas through WIC without needing to pursue prior authorization from MassHealth. A Request for
Special Formula and Food form is required for Enfamil A.R. before issuance will be approved.
WIC does not provide whole cow’s milk for infants. Whole milk is ONLY provided to women and children over the age of 2
-
who have a documented medical condition that warrants the use of a high-calorie special formula or supplement.
The request for formula other than WIC contract formula will require thorough documentation of medical need (including an ICD code)
which warrants its issuance. The request for a special formula is subject to WIC approval. A WIC Nutritionist will complete a thorough
dietary assessment to verify the need for the requested formula. Significant findings will be communicated to you with the participant’s
permission. It is WIC’s policy to re-evaluate the participant’s continued need for the formula on a periodic basis.
WIC Use Only:
Date Received ___________________ ID# ___________________ Site _________ MH contacted? ___ MH approved? ___ Contacted MD? ___
Category: P B N I C
Next Appointment _________ Comments: ____________________________________________________________
Nutritionist’s signature ____________________________________________________________________
Date__________________________
MA WIC forms and formula list can be downloaded from our website at
Revised WIC Form #67, 3/12
For more information, please call WIC at 1-800-WIC-1007.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical