DC WIC requires this federally mandated form before it issues an exempt infant formula or WIC-eligible nutritional for a qualifying medical condition. Infants who aren't exclusively breastfed otherwise receive Similac Advance, Sensitive, Gentle Comfort or Soy Isomil. The prescriber gives the formula, daily ounces, duration and diagnosis, and a WIC CPA authorizes it and sets the expiration date.
A provider with prescriptive authority completes the required sections and signs, checking a credential: MD, DO, PA, CRNA, CNM, CNP, CRNP, NP or DNP. Weight, length or height and hemoglobin are optional, and the WIC CPA signs the WIC-use block.
Download the current version from the source each time; forms change without notice.
DC WIC Medical Prescription 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.
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The form lists MD, DO, PA, CRNA, CNM, CNP, CRNP, NP and DNP as credentials for a health care provider with prescriptive authority. The provider prints their name and phone number, signs and dates the form. All requests remain subject to WIC approval by an authorizing CPA, who records the date received and the prescription expiration date.
The provider can opt in to whole milk or 2% milk for children over 2 and for women, replacing the nonfat or low-fat milk that is standard for those groups. The same food section can request infant cereal and jarred fruits and vegetables for children over 1 and women.