Medical Documentation For Wic Formula And Approved Wic Foods For Infants, Children And Women
ADVERTISEMENT
1
2Medical Documentation for WIC Formula and
NEW YORK STATE DEPARTMENT OF HEALTH
Approved WIC Foods for Infants, Children and Women
Division of Nutrition
WIC Stamp
Instructions: Providers, please complete sections A – C for all WIC participants to
request formula and prescribe supplemental foods. (Further instructions on reverse)
A. PATIENT INFORMATION
/
/
Patient’s Name:
Date of Birth:
B. FORMULA AND WIC SUPPLEMENTAL FOODS (Provision of formula/food subject to WIC policies and procedures.)
☐
☐
☐
Formula Requested:
Length of Use:
1 month
6 months
months
☐
☐
3 months
12 months
Prescribed Amount:
ounces/day
Special Instructions/Comments:
WIC Qualifying Medical Conditions:
WIC Supplemental Foods:
☐
Refer to WIC for determination of foods and amounts
☐
☐
☐
☐
No food restrictions
Premature
Metabolic
Failure to Thrive
☐
Patient cannot tolerate foods: provide formula only.
Birth
Disorders
(Must meet at least one
☐
of the criteria on back)
Issue modified food package omitting foods checked below.
☐
☐
☐
Check the foods that should NOT
WIC Category
Low Birth
Immune System
Severe Food Allergies
be issued to the patient.
☐
☐
Weight
Disorders
☐
☐
☐
Infants (6 - 11 mos.)
Infant Cereal
Baby Food Fruits
☐
GI
Malabsorption
Other (Specify)
Baby Food Vegetables
☐
☐
☐
Disorders
Syndromes
Children (≥ 12 mos.)
Milk
Cheese
Cereal
☐
☐
☐
and Women
Whole Grains
Eggs
Juice
☐
☐
Beans
Peanut Butter
☐
Note: These non-specific symptoms/conditions are not acceptable:
Vegetables/Fruit
dermatitis, formula/food intolerance, fussiness, gas, spitting up, constipation,
☐
diarrhea, vomiting, colic, or to enhance or manage body weight without
Canned Fish (if applicable)
an underlying medical condition.
Provider Stamp
C. HEALTH CARE PROVIDER INFORMATION (Contact information may be printed or stamped and must be legible.)
Provider’s Signature
Date
Street
City, State, Zip Code
Provider’s Printed Name
Telephone Number
Fax Number
D. RELEASE OF INFORMATION
I authorize the above health care provider and NYS WIC agency staff to disclose/discuss information regarding feeding needs. This permission is
good for the length of this certification. I understand that I may cancel this permission at any time by request to my health care provider and WIC.
This release is not a condition of WIC eligibility.
Participant/Parent/Caregiver Signature
Date
Printed Name
E. WIC STAFF USE ONLY (WIC staff must complete section in its entirety and note comments/actions)
Consent on file at WIC
Check box next to question if the answer is yes:
Approved
Disapproved
Pending
Pending Date & Initial
Acceptable qualifying condition indicated?
Signature:
Formula consistent with qualifying condition?
Amount and length appropriate?
Printed Name:
Date:
Med Doc Foods note written?
Comments:
WIC ID #
DOH-4456 (9/14) Page 1 of 2
This institution is an equal opportunity provider and employer.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Wic-11 - Medical Documentation For Wic Formula And Approved Wic Foods For Infants, Children And Women
Medical
Medical Documentation For Wic Formula And Approved Wic Foods For Infants, Children And Women
Medical
Form Doh-4456 - Medical Documentation For Wic Formula And Approved Wic Foods For Infants, Children And Women Form - Nys Department Of Health
Legal
Ccl. 029a Form - Medical Record For All Children In Child Care Facilities And Family Day Care Homes, Including Provider's Own Children
Legal
Related Categories
Parent category: Medical