Pennsylvania WIC needs this one-page authorization, required by federal WIC rules, before it issues specialized formulas, nutrition supplements or a non-contract standard formula, or changes a participant's WIC foods. Clinicians meet it when an infant, child or woman on WIC has a qualifying medical condition. The current version took effect January 1, 2026, and covers formula, food restrictions and dairy substitutions on a single page.
A physician, certified registered nurse practitioner, certified nurse midwife, physician assistant or licensed dietitian nutritionist completes the six numbered items and signs with office contact details. The client's and parent or caregiver's names go at the top; the family does not sign this form.
At the top of the form, enter the client's first and last name and birth date, and the parent or caregiver's first and last name. The client is the WIC participant: the infant or child receiving the formula, or the woman if the authorization is for her. These details let the local WIC clinic match the authorization to the right participant record.
Name the formula and answer the yes or no questions below it: whether WIC may substitute a different brand of comparable formula if needed, whether ready-to-feed is required (it must be justified by the medical condition), and whether the formula is given by tube feeding. Add special instructions for preparation and use if needed. PA WIC may add a product it does not yet carry once it receives the completed authorization.
Give the amount in ounces per day for a formula, or tablespoons per day for a modular formula. For infant formulas only, you can check the WIC maximum monthly allowance under 7 CFR 246.10(e)(9). For a partially breastfeeding infant, the form offers a WIC-determined amount based on WIC's individual assessment instead of a fixed figure.
Check 1 month, 3 months or 6 months, or write an end date; the maximum is 6 months. Pre-discharge premature formulas require monthly renewal, so a new authorization is needed each month for those products. When the authorization lapses, the participant needs a new form before WIC can continue the specialized formula.
Write the qualifying medical condition or conditions with the ICD-10 code. The form states that this item justifies the authorization of the formula above, so the diagnosis should explain why a specialized or non-contract product is medically needed. It also has to support any ready-to-feed request made in item 1.
Check No WIC Food Restrictions, or the foods to withhold. For infants 6 to 11 months: infant cereal, jarred infant meat, and jarred infant fruits and vegetables. For children and women: cow's milk, cheese, yogurt, tofu, plant-based milk, breakfast cereal, whole grains, cash value benefits for fruits and vegetables, 100% fruit juice, canned fish, eggs, beans, and nut and seed butters. Then choose how long the restriction lasts and add reasons.
Either keep WIC's standard dairy, which is whole milk and whole or low-fat yogurt for children 12 to 23 months, and 1% or skim milk with low-fat or non-fat yogurt for children 2 to 5 and women. Otherwise select an alternate milk and yogurt type for the age group. Whole milk for children 2 and over and for women is available only with a prescribed special formula.
The physician, certified registered nurse practitioner, certified nurse midwife, physician assistant or licensed dietitian nutritionist signs and dates the form, prints their name, and gives the medical office or clinic name, address, telephone and fax. WIC uses these details to contact the prescriber about the request, so write them legibly or type them into the PDF.
Download the current version from the source each time; forms change without notice.
Formula Authorization Form
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.
Sources for this guide
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The signature line lists a physician, certified registered nurse practitioner, certified nurse midwife, physician assistant or licensed dietitian nutritionist. The signer prints their name and gives the medical office or clinic, address, phone and fax, which WIC uses to follow up. The parent or caregiver's name appears at the top, but the family does not sign.
The prescriber chooses 1 month, 3 months, 6 months or a specific end date, and 6 months is the maximum. Pre-discharge premature formulas are the exception: they need a monthly renewal. Food restrictions in item 5 carry their own length, 1, 3 or 6 months or another period the prescriber writes in.
Not for the contract formulas. PA WIC holds a contract with Abbott Nutrition for standard Similac formulas. A standard formula outside the contract is approved by WIC case by case and, if approved, needs a completed authorization. Enfamil AR always needs the form, and some products, such as Similac 360 Total Care, are not authorized at all.
Yes. Item 6, Dairy Authorization for Women and Children Only, lets the prescriber keep WIC's standard milk and yogurt or choose an alternate: 2%, 1% or skim, or soy or pea-based milk for children 12 to 23 months, and whole, 2% or plant-based milk for older children and women. Whole milk requires a prescribed special formula.