Wisconsin's F-44024D serves as both a WIC referral and a medical formula or food request for infants and children. Section I shares weight, length or height, birth data, hemoglobin or hematocrit, lead and human milk feeding status, which on its own supports WIC eligibility and remote services. Section II requests an approved formula for a qualifying condition, with the amount, length of use and any food restrictions.
The health care provider completes Section I for every referral and Section II when requesting formula; 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.
Download the current version from the source each time; forms change without notice.
Wisconsin WIC Referral/Request for Medical Formula/Food: Infants and Children
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No. The form lists every Wisconsin WIC approved formula, from Enfamil AR and EleCare to Similac Alimentum, NeoSure and PediaSure Peptide 1.0, and states that write-ins are not allowed. Check the product you need and give the amount and intended length of use.
Yes. Wisconsin DHS says only section 1 is needed when no medical formula or food is requested. Sending height, weight and hemoglobin lets participants receive remote services and reduces repetition at the WIC appointment. Complete both sections for a formula request.
Only with a medical formula and a diagnosis. The food restrictions section offers whole milk or whole milk yogurt for children 24 months or older only in combination with a medical formula, and the WIC dietitian assesses foods if the section is left unchecked.