Medical Documentation Form for WIC Special Formulas and WIC Foods

Georgia WIC Program Medical Documentation Form for WIC Special Formulas and WIC Foods

Note: The Georgia WIC Program only accepts prescriptions authorized and signed by physicians, physician assistants, and nurse practitioners.

Patient’s First & Last Name:     Date of Birth (MM/DD/YY):

Parent/Caregiver’s First & Last Name:

1. Qualifying Medical Condition(s)

List the specific diagnosed or suspected medical condition(s) and the ICD-9 or ICD-10 code(s) justifying the formula/medical food prescription.

Qualifying diagnosed medical condition(s):

And applicable ICD-9 or ICD-10 code(s):

Note: WIC approval and provision of prescription formulas and medical foods are based on Georgia WIC Program policies and procedures.

2. Special Formula Requested

Name of formula/medical food requested:

Prescribed ounces per day: oz/day Form: Powder Concentrate Ready-to-feed

Special instructions/comments:

If Applicable: Flavor: With Fiber: Yes No N/A

Planned length of use: months

WIC prescription renewal is required periodically (every 1-6 months).

3. WIC Foods

Please complete section A or section B below. The patient may receive supplemental foods appropriate to the WIC participant category in addition to the approved special formula.

A. No Supplemental Food Restrictions: (provider initials)

B. If there are prescribed food restrictions due to the patient’s medical condition(s):

In the “Contraindicated Supplemental Foods” column, please check any supplemental foods that cannot be issued due to the patient’s medical condition(s). Please describe any other prescribed restrictions or special requests in the comments section below.

* Only for exclusively breastfeeding women, women pregnant with multiple fetuses, and women mostly breastfeeding multiple infants.

4. Health Care Provider Information (Please Complete All Boxes.)

Original signature required. No stamped signatures or proxy signatures will be accepted.

Note: The Georgia WIC Program only accepts prescriptions authorized and signed by physicians, physician assistants, and nurse practitioners.

Instructions & Resources for Use of This Form

Use this form to request special formulas and/or medical foods for patients with qualifying medical conditions. Refer to Georgia WIC Form #2 for food intolerances or food allergies that can be managed with food substitutions.

If you have questions or need additional clarification, contact the local WIC agency where your patient is receiving WIC benefits. Information about formulas and medical foods approved for issuance by the Georgia WIC Program is available online.

Local agency WIC staff will review requests according to federal regulations and Georgia WIC Program policies and procedures.

Definitions, Examples and Exclusions

Qualifying Medical Conditions: Specific suspected or diagnosed life-threatening disorders, diseases and medical conditions that impair ingestion, digestion, absorption or utilization of nutrients.

Non-Qualifying / Excluded Conditions: Solely for enhancing nutrient intake or managing body weight, non-specific formula intolerance, patient preference, or food dislikes.

Medical Diagnoses: Non-specific symptoms or diagnoses are insufficient; additional documentation may be required if diagnoses are missing or incomplete.

Prescribed Formula Quantity: Amounts provided by WIC are subject to maximum allowable quantities and federal regulations.

Use of Ready-To-Feed Products: Ready-to-feed products may be issued in specific situations such as unsanitary water supply, poor refrigeration, difficulty diluting formula, or when ready-to-feed is the only available product form.

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

USDA non-discrimination statement and contact information applies.