Oregon WIC uses this two-page form, revised May 4, 2026, when a participant needs a non-contract medical formula or changes to WIC foods. The provider gives the diagnosis, length of issuance and daily amount, checks acceptable formulas from the list, then sets food omissions, substitutions and milk-fat changes. A WIC registered dietitian reviews each form and records an expiration date.
A provider supervising the patient's care (MD, DO, NP, PA, ND or CNM) completes sections A through D and signs. WIC staff record the date received, expiration date and RDN review.
Download the current version from the source each time; forms change without notice.
Women, Infants and Children (WIC) 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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Only temporarily. The form states that Medicaid is the primary payer for medical formulas and that WIC can provide them until the health plan's issuance is established. For tube-fed patients, section A asks for the formula name and enteral company, and page 2 says blenderized tube feeding should be referred to Medicaid.
Section D lists MD, DO, NP, PA, ND and CNM. The patient must be under the medical supervision of the signing provider, and you can also give the name of a clinical registered dietitian. A WIC registered dietitian reviews every form before issuance.
Only to adults and children older than 23 months who receive formula from WIC or Medicaid, and the form says there are no exceptions. For children 12 to 23 months, you can instead request low-fat or nonfat milk and yogurt in section C.