Minnesota WIC requires a qualifying medical diagnosis before it provides medical formula or food to infants, contract formula to children over 1, or medical food to women. This form collects the formula, diagnosis, amount, length of use and food package changes. WIC staff review and approve requests under federal regulations and Minnesota WIC policy.
The prescribing provider completes sections A to E. Every field in section E is required: signature, date, printed name, credential (MD, NP, PA, CNM or DO), medical office and phone.
Download the current version from the source each time; forms change without notice.
Minnesota WIC Medical Formula Request 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.
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Yes, if the provider checks it. Section D can order whole milk or yogurt for a child aged 2 to 4 or a woman receiving formula, substitute infant cereal or pureed fruits and vegetables for a child receiving formula, provide formula only, or omit specific WIC foods.
Length of use can be a number of months up to 6, or 'WIC max', which is 6 months. If no length is written, WIC may provide up to 6 months. Patient measurements in section B, such as length, weight and hemoglobin with dates, are optional and entered if available.