Can the form be signed electronically?

Yes. Electronic signatures are generally legally valid under the ESIGN Act and state electronic transaction laws when intent and attribution are documented; consumer-facing disclosures may be required for some records and HIPAA protections must be preserved.

Is notarization required for WIC medical documentation?

Not typically. WIC medical forms generally do not require notarization; if a jurisdiction or local program office requests notarization, follow that office's instructions and local rules.

What if a lab value is entered incorrectly?

Correct the record promptly using an amendment or addendum that notes the correction, who made it, and why. Keep the original entry and the correction history to preserve an audit trail.

Who is authorized to sign the medical attestation?

A licensed clinician with the appropriate credential (for example MD, NP, RD) should sign the attestation. The signer should include printed name, professional title, signature, and date.

How long must these records be retained?

Maintain records per applicable standards: keep program records a minimum of three years for typical federal review, retain HIPAA-related records for six years, and follow any longer state or program-specific retention rules.

How do I correct a submitted form?

Submit a documented amendment or corrected form through the same secure channel used originally. Ensure corrections are dated, include the authorizing clinician's name and credentials, and preserve the audit trail.

Electronic Signature
Templates
Healthcare
Florida Department of Health WIC Program Medical Documentation

Florida Department of Health WIC Program Medical Documentation

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Florida Department of Health WIC Program
Medical Documentation for Formula and Food

The Florida WIC Program supports the American Academy of Pediatrics’ Statement on Breastfeeding and the Use of Human Milk. Final determination of the approval and provision of formula and food will be based on Florida WIC Program policies and procedures.

Client’s Name: Date of Birth:

FORMULA(S) and FOOD OPTIONS

Please read the back of this form for Florida WIC policies and list of qualifying medical conditions.

Enfamil milk-based formulas and Gerber soy-based formulas are the WIC contract formulas. (See the back of this form for more information about the WIC contract formulas.)

To request a substitute, complete all fields below.

Have WIC contract formulas been tried? Yes No Are they contraindicated? Yes No Why?

Formula Name: maximum amount allowed OR specify ounces required per day

Do not issue WIC supplemental foods; provide formula only.

Licensed Dietitian/Nutritionist can determine which WIC supplemental foods to provide.

Child 1 year or older who is prescribed a formula requires the following WIC supplemental foods checked below:

Baby cereal AND baby fruits and vegetables Baby cereal AND regular fruits and vegetables

Issue a modified food package omitting the WIC supplemental foods checked below:

Infant under 1 year: No baby cereal at 6 months of age No baby fruits and vegetables at 6 months of age

Woman or Child 1 year or older: No milk No yogurt No cheese
No fruit juice No beans No cereal No whole wheat bread/pasta/tortillas; brown rice; or corn tortillas No eggs
No fruits & vegetables No peanut butter No fish

Any special instructions or additional restrictions:

Length of use (cannot exceed 6 months): 1 month 3 months 6 months Other, please specify

Qualifying medical condition(s):

Date Anthropometric data obtained: Height or Length: Weight:

Failure to Thrive must be accompanied by current height or length and weight.

MILK SUBSTITUTES and OPTIONS - Only complete this section when applicable.

Child 1 year to less than 2 years old - WIC provides whole cow’s milk OR whole lactose-free cow’s milk.

Soy formula instead of cow’s milk and cheese for: Cow’s milk allergy Vegan diet Lactose intolerance

Check which soy formula: Gerber Good Start Soy 3 Gerber Good Start Soy 1 Other

Woman or Child 2 years or older - WIC provides 1% lowfat or fat free cow’s milk OR 1% lowfat or fat free lactose-free cow’s milk OR soy milk.

If prescribing a formula for a woman or child 1 year or older, what type of milk do you want WIC to provide? Whole milk 1% lowfat or fat free milk 2% reduced fat milk No milk

Any special instructions or additional restrictions:

Must have office stamp or complete practice address and phone number

Print Name

Phone Number

Signature of Physician, ARNP, or PA

Date

Florida Department of Health WIC Program

Medical Documentation for Formula and Food

Dear Health Care Provider:

Thank you for your continuing support of the Florida WIC Program. WIC supports the American Academy of Pediatrics’ Statement on Breastfeeding and the Use of Human Milk. WIC encourages mothers to fully breastfeed their babies for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Local WIC agency staff can assist WIC mothers with breastfeeding or make appropriate referrals.

The Florida WIC Program provides a limited number of milk-based and soy-based formulas for WIC infants who are not fully breastfeeding. (See list of WIC contract formulas below.) The use of federally mandated competitive procurement for standard infant formulas has allowed the program to purchase formula at a greatly reduced cost. Use of the WIC contract formulas provides additional funds for the Florida WIC Program to serve more pregnant, breastfeeding, and postpartum women; infants; and children.

Completion of this form is not needed for infants under 12 months of age to receive a WIC contract formula.

WIC contract standard infant formulas are the following formulas:

Note: All contract formulas have DHA and ARA.

Enfamil Newborn milk-based formula, 80:20 whey-to-casein ratio (To be discontinued by manufacturer in May 2017.)

Enfamil Infant milk-based formula, 60:40 whey-to-casein ratio (400 IU vitamin D in 34 oz)

*Enfamil Gentlease partially hydrolyzed milk-based formula, 60:40 whey-to-casein ratio, 20% lactose

*Enfamil Reguline partially hydrolyzed milk-based formula, 60:40 whey-to-casein ratio, 50% lactose, and a blend of two prebiotics--galacto-oligosaccharide (GOS) and polydextrose (PDX)

Enfamil A.R. thickened milk-based formula, 20:80 whey-to-casein ratio

Gerber Good Start Soy 1 partially hydrolyzed soy-based formula

For ages 9 months and older, the following contract formulas are also available:

Enfagrow Toddler Transitions or Enfagrow Premium Toddler Transitions milk-based formula, 20:80 whey-to-casein ratio

*Enfagrow Toddler Transitions Gentlease partially hydrolyzed milk-based formula, 60:40 whey-to-casein ratio, 25% lactose

Gerber Good Start Soy 3 partially hydrolyzed soy-based formula

*These partially hydrolyzed cow’s milk-based formulas may contain a trace amount of soy protein which is used in the hydrolyzation process.

This form must be completed with a qualifying medical condition for infants to receive a formula other than a contract formula OR for children 12 months and older or women to receive either a contract formula or another formula.

WIC Program Policy for Formulas Other than the Contract Formulas

By completing this form, you are indicating that a diagnosed qualifying medical condition necessitates the use of a different formula(s) from the current contract formulas. The local WIC clinic cannot consider the requested formula(s) without all of the required information.
Substitution of another formula will only be considered if it meets the qualifying medical conditions as described below.
Requests are limited to 6 months. It is our policy to re-evaluate the client’s continued need for the formula(s) on a periodic basis during the requested time period.
In some cases, incomplete or limited medical information may prevent the approval of the formula(s) requested. In order to expedite the approval process, WIC staff may need to contact the health care provider who requested the formula(s) to obtain more detailed medical information. Complete contact information is required on the front of the form.

Qualifying Medical Conditions – formula approvals will be considered for one or more of these reasons:

Premature birth will be considered a qualifying medical condition for children under 12 months of age (adjusted age) to receive a premature formula.
Low birth weight will be considered a qualifying medical condition for infants under 6 months of age (adjusted age) to receive a high calorie formula.
Inborn errors of metabolism and metabolic disorders.
Must specify gastrointestinal disorder or malabsorption syndrome that impairs ingestion, digestion, absorption, or utilization of nutrients that could adversely affect nutritional status.
GER or GERD only with an additional qualifying medical condition.
Immune system disorders.
Must specify life-threatening disorders, diseases, or conditions.
An extensively hydrolyzed formula or amino acid based formula can be provided for a diagnosed formula intolerance or food allergy to lactose, sucrose, milk protein, or soy protein.
Formula or WIC-Eligible Nutritionals will be considered for a diagnosis of “Failure to Thrive” only when the child is documented with one or more of the following: at or below 5th percentile weight-for-length on WHO growth charts for ages under 24 months OR at or below 5th percentile BMI-for-age on CDC Growth Charts for ages 24 months and older OR both the length/height for age and weight for age are at the 5th percentile OR has dropped one growth channel in a 6-month time period which results in the child being below the 25th percentile weight-for-length or BMI-for-age. Current anthropometric data required.

Non-qualifying Conditions – formulas will not be approved solely for one or more of these reasons:

Colic, spitting up, gassiness, or fussiness.
Diarrhea, vomiting, or constipation that is of short duration or intermittent.
“Feeding difficulty” without giving medical diagnosis.
“Medically necessary” without giving medical diagnosis.
“Poor weight gain” without giving medical diagnosis.
Enhancing nutrient intake or managing body weight.
Non-specific formula or food intolerance.
Participant preference.

A standard milk-based or soy-based infant formula (other than the WIC contract formulas listed above) cannot be provided to a WIC participant for formula intolerance or food allergy to lactose, sucrose, milk protein, or soy protein.

No type of formula can be provided to a child or woman with lactose intolerance who is able to drink lactose-free milk.

If you have a question about a specific formula, please contact your local WIC office or the Florida WIC Program at 1-800-342-3556.

This institution is an equal opportunity provider.

What the Florida Department of Health WIC Program Medical Documentation Is

The Florida Department of Health WIC Program Medical Documentation is the provider-completed clinical form used to record medical and nutritional risk factors that determine eligibility for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Florida. The form captures diagnoses, anthropometric measurements, hemoglobin/hematocrit results, feeding history, and a clinician attestation. It supports enrollment, benefit issuance, clinical follow-up, and audit readiness. When handled electronically, the record remains subject to applicable electronic signature rules and HIPAA protections for protected health information.

Why Accurate Medical Documentation Matters for WIC

Accurate Florida Department of Health WIC Program Medical Documentation establishes clinical eligibility, reduces processing delays, supports correct benefit levels, and creates an auditable record for program oversight while protecting patient care continuity and privacy.

Who Completes and Relies on This Medical Documentation

Clinical providers, nutritionists, and WIC clinic staff complete and certify medical documentation for eligibility, monitoring, and referrals within Florida's WIC Program.

WIC clinic Registered Dietitians documenting nutritional risk and counseling outcomes.
Primary care providers verifying diagnoses, anthropometric measures, and lab results for WIC eligibility.
Public health nurses and program administrators reviewing records for eligibility audits and follow-up.

Clear role assignments and training reduce errors, accelerate enrollment, and help maintain program integrity while protecting personal health information.

Stepwise Process to Complete and Submit the Form

Follow these steps to complete and submit the Florida Department of Health WIC Program Medical Documentation accurately and securely.

01

Gather Records: Collect recent labs, growth charts, and clinical notes.
02

Complete Form: Enter diagnoses, measurements, and required attestations.
03

Confirm Identity: Verify patient identity per clinic policy.
04

Submit: Send to WIC office or upload to secure portal.

Configuring an Online Workflow for WIC Documentation

Set up an electronic workflow that enforces required fields, captures an audit trail, and routes completed documentation to the correct WIC office or state system.

Field	Configuration
Signature Field	Require signer name and timestamp
Authentication	Email link or SMS code
Audit Trail	Capture IP, timestamps, and events
Storage	Encrypt at rest with role-based access

Where to File and How Submissions Are Routed

Typical routing and submission options for completed Florida Department of Health WIC Program Medical Documentation.

Local WIC Office: Deliver paper or upload electronic copy to county WIC office.
State Repository: Submit through state health portal where applicable.
Clinic EMR: Attach to the patient's electronic medical record.
Secure Email: Send via encrypted clinical messaging to program staff.

Technical Requirements for eSubmission and eSigning

Technical platforms and formats accepted for electronic completion and submission of the Florida Department of Health WIC Program Medical Documentation.

Supported Formats: PDF, DOCX, and structured XML
Integrations: EMR, state portals, and secure storage
Authentication: Email OTP, SSO, or stronger MFA

Essential Fields and Data Elements Required

Participant ID: State-assigned WIC ID or clinic MRN

Date of Birth: MM/DD/YYYY format; verify against ID

Provider Attestation: Clinician name, credential, signature, and date

Anthropometrics: Height, weight, head circumference entries with units

Lab Values: Hemoglobin/hematocrit value, units, and test date

Consent & Privacy: HIPAA consent status or authorization notes

Consequences of Incorrect or Incomplete Documentation

Eligibility Denial: Incomplete data may cause benefit denial

Overpayment Recovery: Incorrect records can trigger recoupment

Program Audit: Errors increase audit risk and scrutiny

HIPAA Violation: Unauthorized disclosure carries civil penalties

Criminal Liability: Intentional falsification may lead to prosecution

Administrative Sanctions: Provider suspension or referral possible

Common Preparation Errors to Avoid

Omitting test dates, mismatching units (for example using ounces instead of grams), or failing to indicate sample type can invalidate lab values for WIC eligibility determinations and cause processing delays.
Entering nicknames instead of legal names or using inconsistent name formats prevents identity verification and may trigger requests for supporting identification documents.
Failing to record provider credentials, signature, or exact date undermines attestation requirements and may be treated as an incomplete medical determination by program staff.
Submitting unsecured electronic files or emailing unencrypted PHI risks HIPAA violations and may require breach notification and remediation steps.

Timelines, Deadlines, and Typical Processing Expectations

Typical timeframes and processing expectations for completing and using the Florida Department of Health WIC Program Medical Documentation.

Initial Certification:

Complete at first WIC visit; determines immediate eligibility

Lab Validity:

Use tests within 30–90 days as program requires

Recertification:

Annual review or sooner if clinical change occurs

Processing Time:

Local offices typically process within days to two weeks

Audit Window:

Maintain records for audits per retention policy

Practical Use Cases: Real-World Workflows

Two concise examples showing how clinics and public-health partners apply structured medical documentation to support WIC enrollment and audits.

County Health Clinic

A county health clinic converted paper medical documentation to structured electronic forms to speed WIC eligibility determinations.

Cut verification time substantially with validated fields.
Standardized fields reduced data-entry errors, enabled secure uploads to the state portal, and shortened enrollment turnaround while preserving audit trails and patient privacy.

Community Health Center

A federally qualified health center implemented an electronic intake workflow for WIC referrals to centralize records and reduce duplicative data entry.

Improved referral completeness by requiring key fields.
The clinic saw fewer follow-up requests, faster benefit activation, and clearer documentation for periodic program reviews.

eSignature Vendor Pricing and Feature Comparison for WIC Documentation Workflows

High-level vendor comparison focused on starting price, trial availability, and features relevant to secure handling of WIC medical documentation; signNow is listed first per standard comparison format.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day trial, no credit card	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About Completing and eSigning WIC Medical Documentation

Answers to common questions about electronic completion, signature validity, required fields, retention, and correcting errors for Florida WIC medical records.

Need help? Contact support

Can the form be signed electronically?
Yes. Electronic signatures are generally legally valid under the ESIGN Act and state electronic transaction laws when intent and attribution are documented; consumer-facing disclosures may be required for some records and HIPAA protections must be preserved.
Is notarization required for WIC medical documentation?
Not typically. WIC medical forms generally do not require notarization; if a jurisdiction or local program office requests notarization, follow that office's instructions and local rules.
What if a lab value is entered incorrectly?
Correct the record promptly using an amendment or addendum that notes the correction, who made it, and why. Keep the original entry and the correction history to preserve an audit trail.
Who is authorized to sign the medical attestation?
A licensed clinician with the appropriate credential (for example MD, NP, RD) should sign the attestation. The signer should include printed name, professional title, signature, and date.
How long must these records be retained?
Maintain records per applicable standards: keep program records a minimum of three years for typical federal review, retain HIPAA-related records for six years, and follow any longer state or program-specific retention rules.
How do I correct a submitted form?
Submit a documented amendment or corrected form through the same secure channel used originally. Ensure corrections are dated, include the authorizing clinician's name and credentials, and preserve the audit trail.

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