Mississippi WIC uses this request to document the medical need for formula or a medical food for women and for children 1 year and older. The provider records current weight and height, the qualifying diagnosis, the product, amount per day, tube-feeding status and duration, and checks which WIC foods the participant can eat. The clinic reviews it and scans it into the participant's record.
A physician or licensed medical professional with prescriptive authority under state law completes the form, including the oral intake evaluation, and prints and signs their full name with professional designations.
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Request for Medical Formula for Women or Children (>1 yr.)
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Up to three months. The provider writes the number of months, from 1 to 3, in the duration field. The request itself should be no more than 60 days old when it reaches the WIC clinic, so date it when you complete it and send it promptly.
No. Form 263 is titled Request for Medical Formula for Women or Children over 1 year, and the instructions describe it for participants requesting a medical product in those categories. Weight, height and the measurement date are required fields on the form.