California WIC issues medical formulas and WIC-eligible nutritionals only when a participant has a qualifying medical condition and complete documentation from a provider with prescriptive authority, as 7 CFR 246.10(d) requires. Clinicians meet this two-page request when a WIC infant or child needs a specialty formula or a change to WIC foods. Local WIC staff review it and either issue the product on the WIC Card or send the request to the WIC State Office.
A licensed health care provider with prescriptive authority (MD, DO, NP or PA) completes the whole form, Sections I to IV, and checks the matching credential box beside the signature. The parent or caregiver then brings it to the local WIC office unless the provider's office faxes it there.
Enter the WIC agency and WIC ID if known, the patient's name and date of birth, and the parent or caregiver's name and phone number. Record current height or length and weight with the measurement dates, plus birth length and weight, and hemoglobin or hematocrit and a lead test result with the lab date; the form marks these as within 60 days. For infants from birth to 12 months, check the feeding status: fully breastfeeding, breastmilk and formula, never breastfed, or the date breastfeeding stopped.
Check the patient's insurance first. Private insurance is noted as not covering enteral products; if Medi-Cal is checked, the provider submits a Medi-Cal prior authorization and the patient takes the prescription to a Medi-Cal pharmacy. Then check the product from the printed lists (premature, extensive hydrolysate, amino acid, nutritional drinks and other medical formulas) or write the name in. Choose powder, concentrate or ready-to-feed, which needs a written justification, the amount in fluid ounces or ounces per day, and a duration from one to six months.
Check and specify the condition that justifies the product: prematurity with adjusted age in months, low birthweight, failure to thrive, dysphagia, malabsorption with the nutrient named, a genetic or metabolic disorder, a food allergy, an immune system disorder, a gastrointestinal disorder, a life-threatening disorder, or another medical condition. WIC staff look for a specific diagnosis that matches the product; a symptom such as spitting up or fussiness alone will not be approved.
Check no food restrictions if all WIC foods are allowed, or check specific restrictions. For infants 6 to 11 months the options include no infant cereal, no infant fruits and vegetables, no infant foods with increased formula, or, for a premature infant, infant foods only after a set number of months. For children 1 to 5 years they include no milk, cheese, eggs, yogurt, juice, beans, peanut butter, tofu, cereal, canned fish, whole grains or fruits and vegetables, formula only, or purees. Add comments if needed.
Check one credential (MD, DO, NP or PA), print the provider's name, sign and date, and give the office phone number and the medical office or clinic name and address. WIC uses these details to call the provider when the documentation is incomplete or to explain which products WIC can supply. CDPH accepts a handwritten signature or a signature stamp, but the date signed is a required element.
Download the current version from the source each time; forms change without notice.
WIC Medical Formula and Nutritionals 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.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A licensed health care provider with prescriptive authority: a physician (MD or DO), nurse practitioner or physician assistant, who checks the matching box in Section IV. CDPH accepts a signature or a signature stamp, but the documentation must also show the provider's contact information and the date it was signed, or WIC cannot process it.
Up to six months. The form offers durations of one to six months, and CDPH WIC requires new documentation every six months, or sooner if the provider chose a shorter period. A new request is also needed when an infant starts WIC foods at six months and at one year, and when the formula or nutritional changes.
Yes. California WIC accepts a prescription pad or hospital discharge papers, as long as they include every required element: participant's first and last name, qualifying diagnosis, product name, amount per day, duration in months, WIC food restrictions if any, the provider's signature and contact information, and the date signed.
Non-specific symptoms such as colic, constipation, diarrhea, spitting up, picky eating, poor appetite, cramps, fussiness or gas; requests solely to enhance nutrient intake or manage weight without an underlying condition; non-specific formula or food intolerance; and caregiver preference or food dislikes. A specified food allergy requiring an elemental formula can qualify.