Florida WIC needs this one-page request before it gives an infant a formula other than its contract formulas, or gives any formula or nutritional product to a child 1 year or older or to a woman. The clinician names the formula, daily amount, length of use and a written qualifying diagnosis, and can tailor the WIC foods. WIC staff decide under program policy and may call for more detail.
A physician, APRN or PA completes the form, at minimum the shaded areas: client name, date of birth, formula requested, length of use, qualifying medical condition and provider information. The client or caregiver only carries the signed form back to the WIC office.
Enter the client's name and date of birth, then up to two formulas with the amount per day in ounces. For an infant under 12 months who needs a hypoallergenic, elemental or premature powder formula, you can check one product group instead, such as Alimentum, Extensive HA, Nutramigen or Pepticate. WIC then assigns a formula from that group based on availability and can switch it if one runs short. Amount per day may be left blank only for a single formula for an infant under 12 months, who then receives the WIC monthly maximum.
Circle 1 to 12 months; the form does not allow more than 12. Write out each diagnosed condition in words, because WIC does not use ICD codes, and compare it with the qualifying list on side 2. Reviewers turn down reasons such as colic, spitting up, uncomplicated GER/GERD, preference, weight management or "medically necessary" with no diagnosis. A Failure to Thrive diagnosis must come with current height or length, weight and the measurement date, and WIC asks for these for every client when available.
Enter mixing instructions here when the client needs special mixing or the manufacturer does not specify how to mix the product. In either case the amount per day becomes required for every client, infants included. WIC nutrition staff use the two entries together to work out how much formula or nutritional product to issue, and amount per day should be given separately for each formula when more than one is requested.
Leave this blank to give the standard food package. For an infant 6 through 11 months, check formula only, formula and baby cereal only, or formula and baby fruits and vegetables only. For a woman or child 1 year and older, you can choose formula or nutritional product only, give a child on formula baby cereal or baby fruits and vegetables instead of regular ones, pick the milk type, and omit items such as yogurt, cheese, juice, eggs, fish or peanut butter. Whole milk can be selected only when WIC also provides a formula or nutritional product.
A physician, APRN or PA signs and dates the form and includes credentials, then prints or stamps name, address, phone number and fax number. WIC treats the contact details as required, because staff call providers when the medical information is incomplete or limited. The signature date also matters: an approved request is valid for the months you chose, counted from that date, and WIC re-evaluates continued need during the period.
Download the current version from the source each time; forms change without notice.
Medical Documentation for Formula and Food Form
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
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You choose 1 to 12 months on the form, and it cannot exceed 12. Once WIC staff approve it, the request runs for that many months starting from your signature date. WIC re-evaluates the need for the formula periodically during that time and may contact you for updated information before continuing the approval.
Section C is for a physician, APRN or PA, who signs, dates and includes credentials, and prints or stamps name, address, phone and fax number. WIC treats this contact information as required, because staff call the provider when medical information on the form is incomplete or too limited to approve.
Side 2 lists them: prematurity, low birth weight and neonatal abstinence syndrome in young infants, inborn errors of metabolism, specific GI or malabsorption disorders, GER/GERD with another qualifying condition, immune disorders, life-threatening conditions, protein allergy needing extensively hydrolyzed or amino acid formula, and Failure to Thrive that meets the printed growth criteria.
Only if the client should not receive the standard WIC foods. If nothing in Section B is checked, WIC provides all standard foods unless an allergy or intolerance rules one out or the client does not want it. With documented cow milk protein allergy or intolerance, WIC withholds yogurt, cheese and cow milk even when requested.