Wisconsin's F-44024A combines a WIC referral and a medical food request for pregnant, breastfeeding and non-breastfeeding postpartum patients. Section I carries weight, height, hemoglobin or hematocrit, due or delivery date and any need for lactation support; on its own it supports eligibility and lets the patient receive remote WIC services. Section II requests a listed medical food such as Ensure or Boost for a qualifying condition.
The health care provider completes Section I for any referral, and both sections when requesting a medical food; an MD, DO, PA or NP signs, and certified nurse-midwives with prescribing certification also qualify. A WIC registered dietitian nutritionist reviews and fills the request.
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Wisconsin WIC Referral/Request for Medical Formula/Food: Women
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Only if you are requesting a medical food. Section I alone is enough for a referral: it shares the patient's measurements and hemoglobin or hematocrit, which helps WIC determine eligibility and serve the patient remotely. Complete every box in Section II when the patient needs a medical food.
The form lists all approved products: Ensure Nutrition Shake, Ensure Plus, Ensure High Protein, Kate Farms Standard 1.0, Boost Original, Boost Plus, Boost High Protein and Boost Glucose Control. WIC cannot provide more than its maximum monthly amounts, which may not meet the patient's full needs.
No. The instructions say ICD codes are not required. Select a qualifying condition, such as an immune system disorder, gastrointestinal disorder, malabsorption syndrome or another condition that impairs nutrition status, and specify the diagnosis. WIC may ask for more documentation if it is missing, nonspecific or inconsistent with measurements.