Maryland WIC needs this form before it provides any non-contract formula, including non-contract standard milk or soy formulas, or a WIC-eligible nutritional; the contract formulas are Similac Advance and Soy Isomil. The provider checks a qualifying condition, names the product, ounces per day, calorie level and duration, and states any food restrictions. WIC then approves, denies or pends it.
A health care provider with prescriptive authority completes sections 1 to 6, circling a credential from MD, DO, PA, NP, CNP, CRNP, DNP, APN, CNM, CRNA, CNS, MBBS or MBBCh. Both signature and credentials must be present for the form to be accepted.
Download the current version from the source each time; forms change without notice.
Medical Documentation Form
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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No. The quick guide says to select the box for the medical diagnosis and that ICD codes will not be accepted. If the condition isn't listed, write it in words on the 'Other' line, and if no clear diagnosis can be made, describe all the symptoms that explain why a special formula is needed.
No. Weight, length or height, hemoglobin and the measurement date are optional patient medical data. The required parts are patient information, qualifying condition, product and daily amount, duration, the food restriction choice, and the provider's signature with credentials and the date the form was completed.