Children 12 months and older and women in Alabama WIC need this prescription to receive any formula or WIC-eligible nutritional product. The prescriber gives a nutrition-related diagnosis, the product, daily amount and duration, and marks any WIC foods to remove. A WIC dietitian or nutritionist then approves issuance under program policy.
A physician, or a PA or nurse practitioner working under a physician's orders, completes and signs the form. WIC clinic staff record the participant ID, date received and approver.
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Alabama WIC Child/Woman Formula Prescription
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Yes. ADPH states that children 12 months and older and women need a prescription form to receive any formula or WIC-eligible nutritional product. The 111b is that form, and the patient's need must be re-evaluated by the provider every six months, when a new prescription is written.
The form lists milk or soy milk, cheese, yogurt, eggs, juice, fruit and vegetables, cereal, peanut, nut or seed butter, canned fish, beans or peas, and whole grains. Check every food the patient may not eat while on the special formula; if nothing is checked, the WIC dietitian or nutritionist decides.
The instructions define a health care provider as a physician or someone working under a physician's orders, such as a physician assistant or nurse practitioner. The signature, printed name, practice or clinic name and date are all required, and WIC staff complete the approval block at the bottom.