Form Doh961-135 - Wic Formulas And Foods Prescription Form - Infants Birth To 1st Birthday - Washington Department Of Health Page 2
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2Washington WIC Medical Documentation Form - Infants (Birth to 12 months)
WIC is a supplemental food and nutrition program. WIC doesn’t provide all the formula or foods an infant needs each
month. Federal regulations require all WIC programs to obtain a formula rebate contract to help contain costs.
Washington WIC currently provides Similac Advance or Good Start Soy as the standard formulas.
INSTRUCTIONS:
Client Information: Print first and last name, date of birth, and name of caregiver.
1. Alternate formulas
WIC can provide alternate Similac formulas if Similac Advance or Good Start Soy isn’t tolerated. To request Similac
Sensitive, Similac for Spit-up or Similac Total Comfort:
•
Check the appropriate box for either Similac Sensitive, Spit-up or Total Comfort.
•
Go to Box 5 and sign and date the form.
WIC will provide the maximum amount of the alternate Similac formula according to infant category and
o
breastfeeding status until the infant reaches 1 year of age.
If the infant can’t tolerate baby foods between 6-12 months of age, WIC can provide additional formula in lieu of
o
baby foods if the infant has a qualifying medical diagnosis. In this situation, complete the form except 2.B. and
2.C.
2. Formulas that require a qualifying medical diagnosis:
A. Check a qualifying medical diagnosis.
B. Check requested therapeutic formula. Under notes, indicate any special needs (i.e. concentrating formula to
increase calories or ready-to-feed)
C. If a 6 – 12 month old infant is on Similac Advance or Good Start Soy and can’t tolerate infant foods and
needs additional formula, check the formula the infant needs. Complete Box 4 to tell WIC staff to issue only
formula to the infant.
D. Check either: “Allow up to the maximum amount of formula” or indicate the number of ounces per day if the
amount is less than WIC provides. Refer to the table below for the maximum amount of formula allowed per
month as defined by federal regulations.
Infant formula type
Birth - 3 months
4 - 5 months
6 - 12 months
6 - 12 months when
foods not allowed
Powder (reconstituted)
Up to 870 fl. oz.
Up to 960 fl. oz.
Up to 696 fl. oz.
Up to 960 fl. oz.
Concentrate (reconstituted)
Up to 823 fl. oz.
Up to 896 fl. oz.
Up to 630 fl. oz.
Up 896 fl. oz.
Ready-to-feed
Up to 832 fl. oz.
Up to 913 fl. oz.
Up to 643 fl. oz.
Up to 913 fl. oz.
Infant foods
Infant cereal
None
None
24 oz.
None – foods not provided
due to medical diagnosis
Baby food fruits and vegetables
None
None
128 oz.
None – foods not provided
due to medical diagnosis
3. Length of time
Check the number months, or write in a time frame not to exceed 12 months of age.
4. WIC supplemental foods
A. Check WIC Dietitian if you prefer the WIC dietitian to work with the caregiver to assign infant foods and
determine how long the infant should receive these foods from WIC.
B. Check what foods the infant can’t tolerate for medical reasons. WIC provides infant fruits and vegetables on
one check. WIC staff will instruct the caregiver how to choose foods following your directive.
C. Check formula only if the infant can’t tolerate any infant foods, or must delay introduction of foods because of
a medical diagnosis. A medical diagnosis is required if more formula is to be provided in lieu of foods.
D. If this section is left blank, WIC will provide supplemental foods.
5. Healthcare provider information
A. Print name of medical provider, sign and date the form.
B. A signature or stamp is required along with phone number and date. A fax number is recommended.
6. Release of information
This is a voluntary authorization the infant’s caregiver can sign allowing WIC staff to share information with the
healthcare provider.
Additional information
•
WIC staff may call the healthcare provider’s office if there’s missing information or to clarify the request.
•
WIC staff can’t issue formula for more than one month when the form is incomplete.
•
You may fax the completed form to the WIC clinic if the fax number is on the bottom of the front page or the
client’s caregiver may return the hard copy to the WIC clinic.
For persons with disabilities, this document is available on request in other formats.
Call 1-800-841-1410 (TDD/TYY 711) to submit a request.
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