Medical Documentation For Wic Formula And Approved Wic Foods For Infants, Children And Women (Page 2 of 2) in pdf

NEW YORK STATE DEPARTMENT OF HEALTH

Instructions and Resources for WIC Medical Documentation Form

Federal policy limits the issuance of certain formulas to medically fragile participants with qualifying medical conditions.

Use this form to request exempt formulas, WIC-Eligible Nutritionals, standard formulas for infants unable to tolerate solid foods, and/or

supplemental foods for patients with qualifying medical conditions. If you have questions or need additional clarification, please contact

the WIC agency where your patient is receiving WIC benefits. A directory of New York WIC agencies can be found at:

prevention/nutrition/wic/local_agencies.htm.

WIC agency staff will review and fill requests for formulas and supplemental foods according to federal regulations and New York WIC

program policies and procedures. WIC may require additional documentation for prescription approval if diagnoses are missing, incomplete,

non-specific, or inconsistent with anthropometric data. WIC agency staff may contact you if further clarification is needed.

RENEWAL OF THIS FORM REQUIRED PERIODICALLY

SECTIONS A-C ARE COMPLETED BY HEALTH CARE PROVIDER TO REQUEST WIC FORMULA AND FOODS

A. PATIENT INFORMATION (Complete for ALL WIC participants.)

Patient’s Name and Date of Birth: Print WIC participant name and date of birth.

B. FORMULA AND WIC SUPPLEMENTAL FOODS (Complete for ALL WIC participants.)

Check (√) beside one or more of the described medical diagnoses or check (√)“Other” and specify the

WIC Qualifying Medical Conditions:

medical diagnosis. (ICD Codes are not required.)

Severe food allergies: Select for severe or multiple food allergies that require a formula.

Failure to Thrive (FTT) is a severe condition that the NYS WIC Program takes seriously. The patient must meet at least one of the criteria

below that WIC uses to define Failure to Thrive:

• Weight consistently below the 3rd percentile for age;

• Weight less than 80% of ideal weight for height/age;

• Progressive fall-off in weight to below the 3rd percentile; or

• A decrease in expected rate of growth along the child’s previously defined growth curve irrespective of its relationship to the

3rd percentile.

WIC measures heights and weights on participants to monitor their growth.Copies of CDC growth charts used by WIC can be

found at:

Formula Requested:

Write the prescribed formula name and/or brand. See approved NYS WIC formulas at:

prevention/nutrition/wic/approved_formulas.htm

Prescribed Amount:

Specify amount required in ounces/day. (Ranges allowed. WIC max, ad lib, as tolerated are not acceptable.)

Length of Use:

Check (√) the number of months for which the prescription is valid, or enter number of months up to 12.

Special Instructions/Comments: Include details of relevant medical condition, allergies, formula history, etc.

WIC Supplemental Foods: Check one to indicate referral to WIC staff, no food restrictions, formula only, or a modified package.

To modify package, check (√) the foods that should NOT be issued.

C. HEALTH CARE PROVIDER INFORMATION (Complete for ALL WIC participants.)

Licensed health care provider must sign and date. Contact information may be printed or stamped and must be legible.

SECTION D WILL BE COMPLETED BY PARTICIPANT/PARENT/CAREGIVER – Please sign, date, and print name.

SECTION E WILL BE COMPLETED BY WIC STAFF – Please follow WIC program procedure when completing this form.

We appreciate your cooperation and partnership in serving the New York WIC population.

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