Maine WIC issues its contract Similac formulas without paperwork, so any exempt infant formula, medical nutritional or non-contract formula needs this one-page prescription form, revised 08/01/2025. The provider picks the product and qualifying diagnosis, sets the daily amount and duration, and states which WIC foods to omit. WIC staff approve each request.
The patient's health care provider completes all three required sections: A (product and diagnosis), B (amount and duration) and C (credential, signature and date), plus the supplemental foods choices.
Download the current version from the source each time; forms change without notice.
WIC Medical Formula Request Form
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.
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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The form lists prematurity, cerebral palsy, cystic fibrosis, low or very low birth weight, eosinophilic esophagitis, failure to thrive, malabsorption, milk or soy allergy, oral-motor feeding issues or developmental delay, short bowel syndrome, tube feeding, and other conditions the provider specifies.
No. Similac Advance, Isomil, Sensitive and Total Comfort are contract formulas WIC issues without the form. Sensitive, Total Comfort and Spit-Up were reformulated to 20 kcal per ounce and no longer need the former standing order form.
Yes, in the Other Formula Requested field, with a justification if a similar formula is already listed. All requests are subject to WIC staff approval, and sections A, B and C must all be completed for the request to be considered.