When a WIC infant or child leaves the hospital on a special medical formula, this notification lets Alabama WIC order the product around discharge instead of waiting for a clinic visit. It records the diagnosis or ICD-10 code, formula, mixing instructions, 24-hour volume, discharge date and allowed foods, and then serves as the participant's prescription.
Hospital staff complete it: the hospital dietitian signs, and the form also names the health care provider, the hospital or clinic and the parent or guardian. A State WIC staff section records when the form was received, when formula was ordered and when it went to the clinic.
Download the current version from the source each time; forms change without notice.
Alabama WIC Hospital Special Formula Notification
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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For the discharge period, yes. ADPH states the form serves as the participant's prescription and is scanned into the participant's WIC record. Intended length of use can be 1 to 6 months, but the 6-month and 12-month evaluations need a standard 111a or 111b prescription from the community provider.
Item 5 asks whether the participant is currently on WIC, with options for yes and where, do not know, or no and the clinic the family was referred to. Item 6 asks whether the mother was on WIC during pregnancy. The State WIC Office then forwards the form to the appropriate clinic.