Kentucky WIC uses these certificates to authorize non-contract standard formula, exempt formulas, WIC nutritionals and exceptions to WIC foods. One PDF holds three versions: infants under 1, children 1 to 5, and pregnant, breastfeeding and postpartum women. The provider documents the qualifying condition with an ICD-10 code, the product and amount, foods to restrict and how long the documentation is valid.
An MD, DO, PA or NP completes the sections that apply and signs section D. Food exceptions use sections A, C and D, while exempt formula or WIC nutritionals use A through D.
Download the current version from the source each time; forms change without notice.
Certificate for Medical Necessity for Formula and WIC Food Exceptions
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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Pick by age and category: the infant certificate (WIC-200) for babies under 1, the children's certificate (WIC-300) for ages 1 to 5, and the women's certificate (WIC-400) for pregnant, breastfeeding and postpartum women. All three carry Rev. 02/23 and are posted together as the Medical Necessity Forms PDF.
Infants receive the standard WIC foods from 6 months, and children and women receive the appropriate supplemental foods along with the formula. To change that, check the foods that are contraindicated, choose formula only, or, on the child and woman versions, check only the foods WIC should provide.