Washington WIC introduced this one-page fillable form on July 14, 2025 for participants who need a premature, hypoallergenic or other WIC formula or nutritional drink, or a change to WIC foods, because of a qualifying condition. The provider records growth data, formula type, amount and form, whether a prescription went to a pharmacy, foods to allow or withhold, a duration of up to six months and the diagnosis.
A health care provider with prescriptive authority (MD, DO, PA, NP or ARNP, or ND) completes sections 1 through 6 and signs. The caregiver signs section 7, a release that lets WIC staff talk with the provider.
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WIC Medical Documentation Form
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For the period the provider specifies, up to a maximum of six months. Section 4 offers 1 to 6 months or an expiration date no more than six months out, and Washington WIC's prescriptions page lists the validity period among the elements every prescription must include.
Yes, if it contains all the required elements: the formula or food name, amount, qualifying diagnosis, how long it is valid, the provider's contact information, signature and date. Washington WIC accepts other documentation only when every one of these is present.
A health care provider with prescriptive authority. Section 6 lists MD, DO, PA, NP or ARNP, and ND. The caregiver also signs section 7, authorizing WIC staff to discuss the patient's health and nutrition needs with the provider for the length of the current certification.