Arkansas Wic Program - Special Formula Request printable pdf download

Arkansas WIC Program

Special Formula Request

WIC may provide the following formulas with documented medical reason/diagnosis for up to 3 months. Supplemental foods

will only be issued with approval of a physician or advanced practice nurse with prescriptive authority. All prescriptions are

reviewed by a WIC Registered Dietitian.

Name of Infant/Child_________________________________________Date of Birth_________________

Height/Length__________________Weight_____________________ Date Taken___________________

List history of formulas previously tried and resulting symptoms:__________________________________

_____________________________________________________________________________________

__________________________________________________________________________________

Note: Ready-to-Use formula can be issued if the caretaker is physically or mentally unable to prepare formula or if water supply is unsafe.

TO REQUEST A SPECIAL FORMULA:

1. Review the descriptions for use.

4. Circle number of months prescribed.

2. Circle selected formula listed below or on back.

5. Indicate the amount needed per day.

3. Write in diagnosis.

6. Select supplemental foods to be restricted.

Formula

Descriptions for Use

Diagnosis

Duration & Amount

Nutramigen Enflora LGG*—

Sensitivity or allergy to milk and/or soy protein;

1, 2, or 3 month(s)

Mead Johnson

chronic diarrhea, food allergies, GI bleeds;

Note: Need to have tried Gentlease LIPIL

_________oz/day

Nutramigen LIPIL—Mead

Sensitivity or allergy to milk and/or soy protein;

1, 2, or 3 month(s)

Johnson

chronic diarrhea, food allergies, GI bleeds;

Concentrate or RTU forms

Note: Need to have tried Gentlease LIPIL

_________oz/day

only—must meet policy

requirements to receive

Pregestimil LIPIL—Mead

Allergy to milk and/or soy protein; chronic

1, 2, or 3 month(s)

Johnson

diarrhea; short gut; cystic fibrosis; fat

malabsorption due to GI or liver disease

_________oz/day

Alimentum—Abbott

Allergy to milk and/or soy protein; severe

1, 2, or 3 month(s)

malnutrition; chronic diarrhea, short bowel

syndrome; known or suspected corn allergy

_________oz/day

Note: Need to have tried Gentlease LIPIL

Allergy to intact protein and casein hydrolysates;

1, 2, or 3 month(s)

EleCare*—Abbott

severe food allergies; short bowel syndrome;

malabsorption:

_________oz/day

Neocate*—Nutricia

Note: Need to have tried Alimentum,

Nutramigen LIPIL, or Pregestimil LIPIL

Nutramigen AA LIPIL*—

Mead Johnson

Portagen*—Mead

Pancreatic insufficiency, bile acid deficiency or

1, 2, or 3 month(s)

Johnson

lymphatic anomalies. biliary atresia; liver

disease; chylothorax

_________oz/day

Similac PM 60/40—Abbott

Renal, cardiac or other condition that requires

1, 2, 3, 4, 5, 6 month(s)

Note: may prescribe for 6

lowered minerals

months duration

_________oz/day

PKU; Hyperphenylalaninemia

1, 2,3,4,5, 6 month(s)

Phenyl-Free 1*—Mead

Johnson

Phenyl-Free 1 and Phenex I for infants and

_________oz/day

Phenex I*—Abbott

toddlers

Phenyl-Free 2*—Mead

Johnson

Phenyl-Free 2 and Phenex II for children and

Phenex II*—Abbott

adults

Note: may prescribe for 6

months duration

*indicates formula is available in powder only

WIC-51

05/10

Arkansas Wic Program - Special Formula Request

Related Articles

Related forms

Related Categories