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Alabama WIC 111a Infant Formula Prescription

Alabama WIC needs this written prescription before it will give an infant, birth to 12 months, any formula other than its contract milk- or soy-based formulas. The prescriber records a nutrition-related diagnosis, the product, daily amount and duration, and the WIC clinic reviews it against program policy before approving issuance.

Who completes it

A physician, or a physician assistant or nurse practitioner working under a physician's orders, completes and signs the whole prescription. WIC clinic staff fill in the participant ID, date received and approver at the bottom.

Submitting and payment

How to submit it
Fax it to the patient's local WIC clinic or give it to the parent to bring to the WIC appointment. ADPH states that only this form is accepted by WIC clinics for special formula requests.

Good to know

  • Colic, spitting up, fussiness, gas and formula intolerance are not accepted as medical conditions, and WIC will not issue formula only to boost nutrient intake or manage weight.
  • Duration is capped at 6 months. A new prescription is required at the infant's 6-month evaluation, except in chronic diseases such as galactosemia, celiac disease, cystic fibrosis or inborn errors of metabolism.
  • Since April 1, 2026, weight, length and the measurement date are required whenever an increased-calorie infant formula is prescribed. ADPH says to discard all earlier versions of the form.
  • Checking both 'No Infant Cereal' and 'No Infant Fruits or Vegetables' marks the infant as medically fragile, meaning unable to eat solids at 6 months, so more formula can be issued.

Get the official form

Download the current version from the source each time; forms change without notice.

Alabama WIC Infant Formula Prescription

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

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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Frequently asked questions

What happens if an Alabama WIC 111a prescription is not renewed?

WIC issues a standard contract formula instead. The form lists Enfamil Infant, Gentlease, ProSobee, AR and Reguline as the standard contract formulas, and other milk-based, soy-based and lactose-free formulas are not WIC approved. Renewing at the 6-month evaluation lets the provider confirm the special formula is still the right one.

Is an ICD-10 code required on ADPH-WIC-111a?

Either a code or a written diagnosis works. The instructions say the prescription may be accepted if the medical diagnosis or the ICD-10 code is written, but whichever is given must be nutrition related. Special preparation or dilution instructions are required only when the formula should not be mixed according to the package directions.

How much formula can be prescribed on the Alabama infant prescription?

One box gives the WIC maximum for a fully formula-fed infant: 26 fluid ounces a day at 0 to 3 months, 29 at 4 to 5 months and 20 at 6 to 12 months. Otherwise write in a lower amount, sized to support whatever level of breastfeeding the infant has.