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Arizona WIC Formula and Food Request Form

Arizona WIC requires medical documentation before it issues non-contract or special formulas, WIC-eligible nutritionals, any formula for a child or adult, or tailored foods, and this request is the state's own template for it. A WIC registered dietitian, nurse or state-approved nutritionist checks that it is complete and current before issuing.

Who completes it

A prescriptive authority completes and signs it: an MD, DO, naturopathic physician (NMD), PA, NP, certified nurse midwife or homeopathic physician (HMD). The patient's name and birth date may be filled in by an authorized representative even after the prescriber signs.

Submitting and payment

How to submit it
Send the form to the patient's local WIC clinic or give it to the family to bring in, and the clinic scans approved documentation into the participant's record. A verbal order is accepted if written documentation follows within 30 days.

Good to know

  • A doctor's prescription form or letterhead prescription is also accepted if it carries every required element. Signature stamps and facsimile signatures are acceptable.
  • Required elements: patient name and birth date, date completed, formula name and form, daily amount, diagnosis or need, length of request, allowed foods unless deferred to the dietitian, signature, contact details and credentials.
  • Documentation that arrives after the requested length of time has expired is treated as invalid. Chiropractors and medical assistants are among providers without prescriptive authority for Arizona WIC.
  • Women and children receiving formula need new medical documentation at least yearly. AHCCCS pays first for special formula, so WIC may refer AHCCCS members back to their doctor for the AHCCCS certificate.

Get the official form

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

Arizona WIC Program's Formula and Food Request Form

Official page

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.

See how Vero Documents works

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Does Arizona WIC accept a prescription pad instead of the form?

Yes. Arizona WIC lists three acceptable written forms: its Formula and Food Request, a doctor's prescription form, or a prescription on the doctor's letterhead. Any of them must include all the required elements, including the form of formula (ready-to-feed, powder or concentrate), daily amount, diagnosis and length of the request.

What happens if the Arizona formula request is incomplete?

If it names the formula, gives a diagnosis and is signed but misses other elements, WIC calls the office for the gaps and may issue up to three months while complete written documentation is requested within 30 days. Missing any of those three makes it invalid, and staff may take a verbal order and issue one month.