State forms for special formula and WIC foods, WIC referral data, and the medical statements schools and child care need before changing a child's meals.
Clinicians meet three kinds of nutrition program forms. WIC medical documentation, required by 7 CFR 246.10(d), lets WIC issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, or change WIC foods. Examples are California's CDPH 247, New York's DOH-4456, Florida's Medical Documentation for Formula and Food Form and Pennsylvania's Formula Authorization Form. WIC referral forms send height, weight and hemoglobin. School meal medical statements, like the Texas Meal Accommodation for Disability Statement, support meal modifications under 7 CFR 210.10(m).
WIC forms are signed by a licensed provider with prescriptive authority (MD, DO, NP or PA) and list the diagnosis with its ICD-10 code, the product, amount, duration and foods to omit. Most are faxed to the local WIC clinic or carried in by the participant. Georgia and Missouri do not accept signature stamps. School meal statements can be signed by a state-licensed physician, PA, APRN or registered dietitian, and the parent returns them to the school food service director. 15 forms have a Spanish version.
ADPH-WIC-111aPrescription for an infant (birth-11 months) who is not fully breastfed and needs a formula other than the WIC contract formula, with qualifying diagnosis.
ADPH-WIC-111bPrescription required for children 12 months and older and women to receive any formula or WIC-eligible nutritional product.
Notifies WIC that a participant is being discharged from hospital on a special formula so WIC can issue it.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Declaración médica para la modificación de alimentos en los programas de nutrición escolar
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
WIC 400-11Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Georgia WIC RMFMedical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
WIC Form FD 141CMedical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Clinician referral documenting medical necessity for a WIC-issued breast pump (e.g. infant hospitalization, prematurity, maternal condition).
Appendix NS-2-GMedical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Exhibit 7-DMedical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
WIC-61Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification for a child or adult participant in the Child and Adult Care Food Program (child care centers, day care homes, adult day care), per 7 CFR 226.20(g).
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Records a child's length or height, weight, hemoglobin or hematocrit and lead results from the provider's office so the family can supply them for WIC participation.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
DOH-4456Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
DOH-799Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
ODH Form No. 351 K39Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
D-4113Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Meal modification request covering school meals and CACFP/SFSP agencies; Part B box A (disability affecting a major life activity) requires a recognized medical authority's statement.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
PH-3151Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
EF16-03-13158Medical request for WIC to issue metabolic formula/medical foods for an inborn error of metabolism.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Declaración médica para solicitar comidas especiales, adaptaciones, sustitutos de leche
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
DOH 961-135Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Combined WIC referral (height, weight, hemoglobin) and request for medical formula/food for an infant or child with a qualifying condition.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Combined WIC referral and request for medical formula/food for a pregnant, breastfeeding or postpartum patient.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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WIC medical documentation forms ask for the qualifying diagnosis and ICD-10 code, the formula or nutritional product, the amount, length of use, any WIC foods to omit, and the provider's signature. Washington accepts other formats only if they include the product, amount, qualifying diagnosis, duration, provider contact, signature and date. California also accepts a prescription pad or hospital discharge papers with every element. Iowa's 470-0092 must be filled out in its entirety to be valid.
It depends on the state. New Jersey asks for updated documentation every three months. California wants an update every 6 months, Missouri's WIC-27 must be renewed at least every 6 months, and Washington's DOH 961-135 lasts as long as the provider specifies, up to 6 months. Nevada's form offers 3 months, 6 months or until 12 months old. In Vermont, infant documentation stays in effect until age 1.
States reject non-specific symptoms. California does not approve colic, spitting up or intolerance. Minnesota lists formula intolerance, spitting up and weight management as not acceptable, and Virginia's WIC-395 names colic, eczema and spitting up as non-qualifying. Louisiana treats diarrhea and constipation as non-qualifying. Medicaid is the primary payer for special formula in California (Medi-Cal) and for dually enrolled patients in Connecticut (HUSKY).
A state-licensed healthcare professional, such as a physician, PA or APRN, or a registered dietitian. Under USDA memo SP 07-2025, school food authorities must accept registered dietitian statements from July 1, 2025. Several states, including Illinois, Montana and Nebraska, need the statement only when the change falls outside the meal pattern. In North Dakota a modification stays in place until the parent or medical professional revokes it.