Alabama Wic Child/woman Formula Prescription

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Alabama WIC Child/Woman Formula Prescription
Prescription is subject to WIC Approval Based on Program Policy and Procedure
Date_________________
Patient s Name _____________________________ Date of Birth___________
ICD-9 Code and/or Medical Diagnosis__________________________________
Federal Regulations prevent formula issuance solely for the purpose of enhancing nutrient
intake or managing body weight with no underlying condition.
Formula Prescribed _________________________________________________
Amount per day
ounces*
__________
.
*Maximum issuance per day allowed by USDA is 30 ounces
Intended length of use
1
2
3
4
5
6 months
· After 6 months a new prescription is required
· If prescription is not renewed, no formula can be issued
Supplemental Foods Available: In addition to medical formula, the WIC Program
may provide supplemental foods as appropriate. Food items will be issued only if
ordered by the health care provider.
Please check all that apply and line through items not allowed.
Juice
Milk and Cheese
Cereal
Eggs
Whole Wheat Bread
Dried Beans/Peas
Peanut Butter
Fresh Fruit/Vegetables
Signature of Health Care Provider ____________________________________
Provider s Name (Please print) _______________________________________
Phone (___) ____________________________ Fax (___) _________________
If you have questions please call your local WIC clinic.
WIC Clinic Use Only
CHR # __________________
Date Received __________
Approved by ___________________
ADPH-WIC-111b-7-09

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