South Carolina WIC requires this documentation for infants and other participants who need a special medical formula rather than the Similac contract formulas. The prescriber checks ICD-coded diagnoses, adds growth data, names the formula, amount, length of use and physical form, and chooses how WIC supplemental foods are handled. Health departments order approved special formulas, and delivery can take seven or more days.
A health care professional licensed to write prescriptions under South Carolina law completes and signs all five sections, filling in every provider box. WIC staff record the participant ID.
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WIC Medical Documentation Form for Formula
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Up to 6 months. Section 3 offers 1 to 6 months, or up to the infant's first birthday without exceeding 6 months. The instructions make one exception: a prescription for metabolic formula may run up to one year.
Two medical diagnoses, supported by anthropometric data. One must be GERD, and the other must be a related condition such as a history of GERD surgery like fundoplication, failure to thrive, weight loss or inadequate weight gain, or frequent pneumonia.
Approved special formulas are not contract formulas, so the health department orders them, and the form warns that delivery can take seven or more days. The prescription also remains subject to WIC approval under program policy, so check the SC WIC approved formula list before writing it.