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Washington WIC Medical Documentation Form - Infants (Birth to 12 months)

Infant’s Name _______________________________________________

Date of Birth _____________________

Caregiver’s Name ____________________________________________

Alternate Formulas (19 calories per fluid ounce)

WIC provides Similac Advance and Good Start Soy as standard formulas. WIC provides alternate formulas when

there’s an assessed need. After completing the assessment, check the formula needed.

 Similac Sensitive for lactose sensitivity

For this section: The selected formula is provided until 12

 Similac for Spit-Up for excessive spitting up

months of age. Supplemental foods are added at 6

 Similac Total Comfort for digestive issues

months. If the infant can’t tolerate baby foods between 6-

12 months of age and needs additional formula in lieu of

Skip to Box 5

foods, complete all boxes except 2.B and 2.C.

. Formulas that require a qualifying medical diagnosis:

Check a qualifying diagnosis:

 Premature birth ≤ 37 weeks gestation

 Gastrointestinal disorders/malabsorption syndromes

 Low birth weight ≤ 5 lbs. 8 oz.

 Severe food allergies: must explain under Notes

 Metabolic disorders/inborn errors of metabolism

 Failure to thrive

 Immune system disorders

 Other medical diagnosis or condition that impacts nutritional status: m

ust explain under Notes



Prescribe therapeutic formula

Notes:

Gerber Extensive HA

 Similac NeoSure (22 kcal/oz.)

 Enfamil Nutramigen

 Enfamil EnfaCare (22 kcal/oz.)

 Similac Alimentum

C. For 6 – 12 month old infants on standard WIC formulas who can’t tolerate baby foods

(must complete 4.C.)

 Similac Advance (20 kcal/oz.)

 Good Start Soy (20 kcal/oz.)

Prescribe amount



Allow up to maximum amount, WIC Staff and caregiver will determine amount OR ____ ounces per day (not to

exceed the maximum amount of formula allowed by WIC listed on back)

3. Length of time

 3 months

 6 months

 until 12 months of age

 Other:_______( not to exceed 12 months of age)

4. WIC supplemental foods:

Unless indicated below, WIC provides supplemental foods at 6 months of age.

A.  WIC Dietitian to determine type and amount of supplemental foods, and length of time

B.  No Infant Cereal

 No Infant Fruits/Vegetables

C.  For 6 – 12 month old infants: formula only – provide additional formula in lieu of infant foods due to inability or

in consuming solids. Indicate a qualifying diagnosis in Box 2. A.

delay

5. Healthcare provider information

Name: __________________________________________________________________Date: ______________

Print or Stamp

Signature: ____________________________________Phone: (____)___________Fax: (____)_______________

6. Release of Information – signed by caregiver

I authorize Washington WIC staff to talk to my health care provider about my child’s health and nutrition needs. This permission

is good for the length of this certification. I understand that I may cancel this permission at any time by written request to WIC

staff. This release isn’t a condition of WIC eligibility. This release doesn’t include these conditions: sexually transmitted disease,

mental health concerns and chemical dependencies.

_______________________________________________________________ _______________________

Caregiver Signature

Date

_______________________________________________________________

Printed Name

WIC Clinic:

____________________________

Phone: _______________ Fax: _______________

Instructions for this form are on the back. Questions? Call the infant’s local WIC clinic or the Washington State Nutrition

Program at 1-800-841-1410. For more information go to:

BREASTFED BABIES ARE HEALTHIER. WIC SUPPORTS BREASTFEEDING

DOH961-135 October 2016

Form Doh961-135 - Wic Formulas And Foods Prescription Form - Infants Birth To 1st Birthday - Washington Department Of Health

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