Formula And Food Authorization Form - Utah Wic printable pdf download

Utah WIC Program

Formula and Food Authorization

Infants up to 12 Months of Age

Please complete each section below or formula/foods cannot be issued. Only complete one row for formula amount.

If specific amount per day is not checked/indicated, then the formula cannot be provided.

A. Patient’s Name: ________________________________ Patient’s DOB: ______________

Parent/Guardian Name: __________________________ Today’s Date: _______________

Primary Care Physician : __________________________Discharging Physician:____________________

B. Medical Diagnosis –

Check all that apply

Allergies

GERD

Feeding Difficulties

Prematurity

Cystic fibrosis

FTT

Malnutrition

Other ICD 10 Medical Dx:

_______________________

C. Name of



Formula/Product:

 powder

 concentrated liquid

 ready to feed (RTF)

Physical Form of Formula:

Partially Breastfed Infant

 3

 6

 9

 12

 Other: ____oz/day

(no ranges)

Formula Amount (oz/day):



 18

 21

 24

 27

 30  32

 Other: ___ oz/day

Fully Formula Fed Infant

(no ranges)

Formula Amount (oz/day):

From 6 months until one year of age, WIC infant foods are available in addition to the

D. WIC Infant Foods

prescribed formula. If nothing is marked below, all foods will be issued.



 No infant cereal

 No infant fruits and infant vegetables

6 - 11 month old infant who is medically unable to consume complementary foods. Provide the maximum formula

amount of 31 oz/day for a 31 day month or 32 oz/day for a 30 day month.

 1 mo.

 2 mo.

 3 mo.

 4 mo.

 5 mo.

 6 mo.

E. Months of Issuance

(6 months will be issued including

Order will continue through the end of the expired month.

current month if nothing is marked)

**See reverse for exceptions



F. Health Care Provider Information

(A written or stamped signature is acceptable.)

 MD

 DO

 NP

 PA

State Licensed Prescriptive Authority

_______________________________

Signature

Clinic/Hospital

____________________________________

___________________________________

Fax#

Phone #

WIC USE ONLY

Approved by:

Received in Clinic Date:

FAFAF Expiration Date:

See Instructions on Back

Utah WIC Program 5/8/2017

Formula And Food Authorization Form - Utah Wic

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