Utah WIC uses this authorization when a child 1 to 5 years old or a woman needs a medical formula or nutritional product, or changes to WIC foods and milk. The provider checks at least one diagnosis, names the product and an exact daily amount, marks foods to withhold or substitute, and sets the months of issuance. The WIC clinic records the approval and the authorization's expiration date.
A Utah state-licensed prescriptive authority (MD, DO, NP or APRN, PA or CNM) completes sections A through F and signs; a written or stamped signature is accepted. Section A also asks for the primary care and discharging physicians.
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Formula and Food Authorization Form (FAFAF) - Children 1 to 5 years of age and women
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No. Section C says ranges are not accepted and that the product cannot be provided if a specific amount per day isn't given. Check one of the listed ounce amounts or containers per day, or write a single exact figure under Other.
Yes, with this form. Standard issuance for children over 2 and women is skim or 1% milk, and section D lets the provider substitute 2% or whole milk. For children 1 to 2, standard issuance is whole milk, with skim, 1% or 2% available as substitutions.
The provider chooses 3, 6, 9 or 12 months, or another period under 12 months, in section E. If nothing is marked, WIC issues six months including the current month, and the order continues through the end of the month.