Iowa WIC requires medical documentation to authorize special formulas and supplemental foods, and this three-page request is the state's form for it. The provider gives the formula and physical form, ounces per day, preparation, length of use and a qualifying condition with its ICD-10 code, then decides whether WIC dietitians may choose the foods.
An MD, DO, PA or ARNP completes sections A to E and signs. The participant or caregiver signs the section F release, and WIC staff complete section G.
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Iowa WIC Program Request for Special Formula and Food
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Section E calls for the signature of an MD, DO, PA or ARNP, with printed name, medical office, phone and date. The patient or caregiver separately signs the bilingual release in section F, which lets WIC and the provider share the information used to provide nutrition services.
Iowa WIC policy accepts other written documents if they contain all the required elements. The 470-0092 lays those elements out in one place: formula, physical form, daily amount, preparation, length of use, qualifying condition with ICD-10 code, food decisions and the prescriber's signature and credentials.