Utah Wic Program Formula And Food Authorization Form (Page 2 of 2) in pdf

Utah Wic Program Formula And Food Authorization Form Page 2

Instructions to Complete

Utah WIC Formula and Food Authorization Form

Children at 12 Months of Age or Older and Women

Step A: Complete patient information.

Step B: Indicate all medical diagnoses that apply to patient. If diagnosis is not listed, please write in the ICD 10

Medical Diagnosis that applies.

Step C: Formula/Product



List name and brand of formula required.

Authorization should be based on medical need and not patient preference.



Specify if the requested formula is powder, concentrated liquid, or ready to feed.



Indicate quantity of authorized food or formula needed per day. Please give specific amount

needed -no ranges can be accepted.

NOTE: Breastfeeding mothers may request less.

Step D: Please indicate if WIC supplemental foods are allowed or if there are any restrictions. Full provision of

WIC food packages are listed below.

Step E: WIC can only give clients ≥ 2 years of age whole milk if they are receiving a medical specialty formula and

require additional calories.

Step F: Specify the length of time this formula and food authorization will be valid.

Step G: Health Care Provider Information must be signed by a Utah state licensed prescriptive authority.

Full Provision of WIC Foods*

Children and Women



Eggs - 1 dozen/month

Juice - 1 gal/month

(Children approximately 4 oz/day)



Fruits/Vegetables - $8-$11



Whole Grains - 1-2 lbs/month



Cereal - 36 oz/month



Beans - 1 lb/month



Milk - up to 4 gal/month



Peanut Butter - 16 - 18 oz/month

(Children approximately 13 -17 oz/day)

*If formula is needed, maximum allowance 29-30 oz/day based on number of days in month or no

more than 910 oz per month.

Utah Wic Program Formula And Food Authorization Form Page 2