Utah WIC uses this two-page authorization when an infant up to 11 months needs a formula or product other than its Similac contract formulas, or can't eat complementary foods. The provider checks at least one diagnosis, names the product, physical form and an exact daily amount, notes whether the infant can take infant foods, and sets the months of issuance. Instructions and WIC amounts are on the back.
A Utah state-licensed prescriptive authority (MD, DO, NP or APRN, PA or CNM) completes sections A through F and signs; written or stamped signatures are acceptable. WIC staff record the approval and expiration date.
Download the current version from the source each time; forms change without notice.
Formula and Food Authorization Form (FAFAF) - Infants 0 to 11 months-of-age
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Not for the contract formulas. Utah WIC receives a rebate on Similac Advance, Similac Soy Isomil, Similac Sensitive (except the concentrate) and Similac Gentle Comfort, and the form says no FAFAF is required to issue them to infants 0 to 11 months.
Check the box in section D stating the infant is medically unable to consume complementary foods by mouth. WIC then provides formula, up to the prescribed amount, instead of the jarred infant fruits, vegetables and cereal that infants 6 to 11 months normally receive.
Yes. Section F lists the Utah state-licensed prescriptive authorities who may sign: MD, DO, NP or APRN, PA and CNM. A written or stamped signature is acceptable, and the form also asks for the clinic or hospital, phone and fax.