Georgia WIC uses this two-page request to provide special formulas, medical foods and tailored supplemental foods for patients with a serious diagnosed condition. The prescriber documents the diagnosis, formula, daily amount, form, length of use and allowed foods. Local WIC staff review it against federal rules and Georgia policy, and approvals run from 1 to 12 months.
A physician (MD or DO), physician assistant or nurse practitioner completes sections 1 to 4 and signs. The participant or caregiver signs the section 5 release, and a WIC CPA records the approval.
Download the current version from the source each time; forms change without notice.
Request for Medical Formulas and WIC Supplemental Foods
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.
The prescriber sets a planned length of use of 1 to 12 months in section 2, and Georgia WIC provides special formulas for intervals in that range. At a minimum, a new medical authorization is required at each participation renewal or formula change. The patient's release also lasts through the planned length of use.
No. Georgia WIC accepts requests authorized and signed only by physicians (MD, DO), physician assistants (PA, PA-C) and nurse practitioners such as NP, APRN, CPNP, CNP, PNP or CNNP. An original signature is required, and stamped signatures or proxy signatures by office staff are not accepted.
Only with additional justification, unless ready-to-feed is the only form the product comes in. Section 2 asks for powder, concentrate or ready-to-feed, plus flavor and fiber where relevant. Premature infants can also keep receiving infant formula past their first birthday with documentation, to account for adjusted age.