Form Odh 3989.23 - Ohio Wic Prescribed Formula And Food Request Form

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Ohio WIC Prescribed Formula and Food Request Form

All requests are subject to WIC approval and provision based on program policy and procedure. Medical documentation is

federally required to issue special formulas. Please complete sections A-D of this form in full.

A. Required Patient Information

Patient’s Name:_______________________________________________________ Date of Birth: ________________________

Parent/Caregiver’s Name:_________________________________________ Weeks Born Early (if applicable): _______________

Medical Diagnosis/Condition :_________________________________________________________________________________

(Medical diagnosis must be specific and correlate to the requested formula.)

B. Required Special Formula Information

Amount of formula to be provided per DAY (must be measurable):___________________________________________________

Special Instructions/Comments:_______________________________________________________________________________



Intended length of use:

1 month

2 months

3 months

4 months

5 months

6 months (maximum)



Has a trial with Gerber Good Start Gentle, Gerber Good Start Soy, or Gerber Good Start Soothe been completed?:

Yes

If “No,” please indicate why:__________________________________________________________________________________

Infants

 Alfamino Infant 

 Neocate Infant w/ DHA & ARA

 Similac Alimentum

 Enfamil Human Milk Fortifier 

 EleCare for Infants

 Neocate Nutra (≥ 6 mo. age)

 Similac Human Milk Fortifier

 Enfamil Nutramigen

 Enfamil AR

 Neocate Syneo Infant 

 Similac NeoSure

 Enfamil Nutramigen w/ Enflora LGG

 Enfamil EnfaCare

 Pregestimil



 Similac PM 60/40

 Enfamil Premature 24 Calorie

 Enfamil Gentlease (RTF only)

 PurAmino DHA/ARA

 Similac Special Care Premature

 Gerber Extensive HA

24 Calorie

Children

 Alfamino Junior

 Compleat Pediatric

 Nutren Junior with Fiber

 PediaSure Peptide

 Boost Breeze

 Compleat Pediatric Reduced Calorie 

 PediaSure

 PediaSure Peptide 1.5 Cal

 Boost Kid Essentials 1.0 Cal (retail)

 Elecare Junior

 PediaSure Enteral

 Peptamen Junior



 Boost Kid Essentials 1.5 Cal

 Neocate Junior

 PediaSure with Fiber

 Peptamen Junior with Fiber

 Boost Kid Essentials with Fiber 1.5 Cal

 Neocate Jr. w/ Prebiotics

 PediaSure with Fiber Enteral

 Peptamen Junior with Prebio

 Bright Beginnings Soy Pediatric Drink

 Neocate Splash

 PediaSure 1.5 Cal

 Peptamen Junior 1.5 Cal

 Carnation Breakfast Essentials

 Nutren Junior

 PediaSure 1.5 Cal with Fiber

 Super Soluble Duocal

Women

 Boost

 Boost Breeze

 Carnation Breakfast Essentials

 Ensure

 Super Soluble Duocal

For PKU and Metabolic Needs: WIC collaborates with the Ohio Metabolic Formula Program which supplies certain metabolic formulas prescribed by an Ohio

Department of Health (ODH) approved metabolic service provider. A separate form must be completed. Please contact your WIC office for more information.

C. Required Supplemental Food Information

WIC Health Professional will issue age appropriate supplemental food unless indicated below.



No WIC supplemental foods: provide formula only.



Issue a modified food package OMITTING the supplemental foods checked below:



Infant cereal

Infant fruits and vegetables

Infants (6-11 months):



Milk