Michigan WIC requires this two-page request before it issues a special formula, gives a contract formula to a child 12 months or older, or changes WIC foods for a client with a qualifying condition. The prescriber checks the condition, names the formula with its daily amount and duration, and can restrict or substitute foods. WIC may call the office for more information before issuing.
A health care provider licensed to write prescriptions under Michigan law completes all applicable sections, including the client's name, date of birth and parent or guardian, and signs Section 4 with name, address, phone and fax. WIC clinic staff complete the clinic-use box, which can record an approved-through date.
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Michigan WIC Special Formula/Food Request
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Section 1 lists preterm birth under 37 weeks, low birth weight of 5 lbs 8 oz or less, failure to thrive, severe food allergies, immune system disorders, inborn errors of metabolism, gastrointestinal or malabsorption disorders and other conditions that impair nutrition. MDHHS instructions say colic, gas, constipation, fussiness, vomiting, rash and non-specific intolerance are not indications for a special formula.
Only when necessary. The DCH-1325 instructions allow a telephone order to a WIC Competent Professional Authority if it contains all the required medical documentation, but the written DCH-1326 must reach the WIC clinic within two weeks. Otherwise send the original request by fax or encrypted email.
The duration you enter in Section 2 cannot exceed 12 months. You name the formula from the full Authorized WIC Formulas list and the ounces needed per day; MDHHS notes that WIC maximums may not meet a client's full nutritional needs. Section 3 is optional, and if left blank WIC chooses foods from 6 months.