Indiana WIC needs this documentation before it issues exempt infant formula, WIC-eligible nutritionals or tailored foods for a patient with a qualifying condition. The provider checks the conditions, names the formula, daily amount and physical form, chooses the allowed foods by age, and sets a length of use. WIC staff scan the form into the client's record.
The health care provider completes each section and signs, adding the medical office, phone and address. Before WIC faxes anything back to the provider, the client signs an Indiana WIC Release of Information at the clinic.
Download the current version from the source each time; forms change without notice.
Medical Documentation 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.
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The provider chooses 1, 3, 6 or 12 months, with 12 months the maximum approval, or writes another length. A length of use is required even when the order covers only food alternatives, such as pureed fruits and vegetables or a different milk, with no formula.
Only if you authorize it. Section 2 asks whether WIC may issue a comparable formula when the prescribed one is hard to find, for example during a recall or supply chain problem. If yes, staff may substitute within the same formula type, such as another extensively hydrolyzed or amino acid based infant formula.