New York State WIC can issue exempt infant formula, WIC-eligible nutritionals and modified foods only for participants with a qualifying medical condition, and this two-page form is how the prescriber documents that need. It also requests extra standard formula for infants 6 months or older who can't tolerate solids, and standard formula for children 12 months or older. Local WIC nutrition staff review it against federal rules and state program policy.
A health care provider with prescriptive privileges (the form lists MD, NP and PA) completes Sections A to D and signs and dates Section D. The participant, parent or caregiver signs the release of information in Section E, and WIC staff complete Section F.
Complete for all patients. Print the WIC participant's name and date of birth. The participant is the person who will receive the formula or foods, so for an infant this is the infant's name, not the parent's. WIC staff add the participant's WIC ID number later in Section F.
Item 1 names the prescribed formula or WIC-eligible nutritional; WIC can only provide products on the NYS WIC Formulary, and you may list more than one to allow for availability. Item 2 is the product form: powder, concentrate or other (ready-to-use is limited to certain conditions). Item 3 is the amount: check 20-32 oz/day (WIC Max) or write ounces per day. Ranges are allowed; ad lib or as tolerated are not.
Item 4, length of use: for infants, give the number of months or check Until Age 1; for children and women, give the months, up to 12. Item 5 holds special instructions, such as the relevant condition, allergies and formula history. Item 6 needs at least one WIC qualifying medical condition from the list, or Other with the diagnosis named. Non-specific symptoms such as fussiness, gas or colic are not acceptable.
Complete only when foods should be restricted. For infants 6 to 11 months, check solids (provide formula only), infant cereal or fruits and vegetables as not allowed. For children 12 months or older and women, options include solids replaced by infant foods or formula only, and withholding cheese, milk or yogurt, canned fish, eggs, peanut butter, soymilk or tofu. If left blank, WIC staff decide which foods to issue.
The provider with prescriptive privileges signs and dates the form and gives a printed name, phone and fax numbers and office address. A provider stamp can supply the contact details, but it must be legible. WIC nutrition staff use these details to reach the prescriber if a diagnosis is missing, non-specific or inconsistent with anthropometric data, or if anything else needs clarification.
Section E is for the participant, parent or caregiver, who signs, prints a name and dates a release letting the provider and NYS WIC staff discuss feeding needs for the length of the certification; it can be cancelled at any time and is not a condition of WIC eligibility. Section F is completed by WIC staff, who record the WIC ID, consent, and whether the request is approved, pending or disapproved.
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Medical Documentation Form
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A health care provider with prescriptive privileges must sign and date Section D; the section heading lists MD, NP and PA. Contact information may be stamped but must be legible. Separately, the participant, parent or caregiver signs the release in Section E, which lets the provider and WIC staff discuss the patient's feeding needs for the length of the certification.
For infants, it runs for the number of months the provider writes in, or until age 1 if that box is checked. For children and women, write the number of months, up to 12. A new prescription is required for each WIC certification, which is usually every 12 months.
No. The instructions say ICD codes are not required. Check one or more listed qualifying conditions, such as failure to thrive, malabsorption syndromes, metabolic disorders or severe food allergies, or check Other and name the diagnosis. WIC may ask for more documentation if a diagnosis is missing, non-specific or inconsistent with the patient's growth measurements.
WIC nutrition staff decide whether to issue the participant's supplemental foods. Fill in Section C when foods should be withheld: infants 6 to 11 months who can't tolerate solids get more formula instead, and children 12 months or older and women who can't tolerate regular solids can receive infant cereal and infant fruits and vegetables.