Utah Wic Program Formula And Food Authorization Form printable pdf download

Utah WIC Program Formula and Food Authorization

Children at 12 Months of Age or Older and Women

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

FTT

Malnutrition

Other ICD 10 Medical Dx:

fibrosis

_______________________

C. Name of



Formula/Product:

 powder

 concentrated liquid

 ready to feed (RTF)

Physical Form of Formula:

 8

 16

 24

 27

 Other: ________oz/day

(no

ranges)

Formula Amount (oz/day):

 1

 2

 3

 3.5

RTF/Single Serving Product

(cans/day):



D. WIC Supplemental Foods –

Age appropriate foods will be issued if nothing is marked.

 No cereal

 No milk

 No wheat bread/brown rice/tortillas/pasta

 No juice

 No cheese

 No dry beans/canned beans

 No fresh fruits/vegetables

 No yogurt

 No canned fish

 No eggs

 No peanut butter

Please indicate medical reason/qualifying condition if prescribing whole milk.

E. Whole Milk/Other

Note: Personal preference is not a qualifying condition.

 Allow whole milk for a child > 2 years or a woman. WIC participant

Medical Reason/

Qualifying Condition:

must have a medical condition, requiring a medical formula, to receive

whole milk.

For children, allow jarred infant fruits and vegetables.

Substitute infant cereal for breakfast cereal.

 1 mo.

 2 mo.

 3 mo.

 4 mo.

 5 mo.

 6 mo.

F. Months of Issuance

(6 months will be issued including

current month if nothing is

Order will continue through the end of the expired month.

marked)

G. 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 6/7/2017

Utah Wic Program Formula And Food Authorization Form

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