ITCA WIC, the tribal WIC agency serving tribes in Arizona, needs this authorization whenever a client is prescribed a formula other than Similac Advance, Sensitive, Total Comfort or Soy Isomil. It also authorizes extra formula in place of infant foods at 6 to 11 months and supplemental foods for women and children on a special formula.
The health care provider completes the whole form: formula and physical form, medical diagnosis, ounces per day, length of time and food requests, then signs and adds name and office details. Weight, length and hemoglobin or hematocrit are optional.
Download the current version from the source each time; forms change without notice.
ITCA WIC Special 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.
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No. The form states that standard formulas do not require a medical diagnosis, and their length of time can run until the first birthday. Hydrolyzed, premature and other formulas, such as Alimentum, Nutramigen, NeoSure, EnfaCare and Enfamil AR, need a documented qualifying condition and a length of time of up to six months.
Yes. Each formula row has columns for powder, concentrate and ready-to-feed, plus 'any form' and 'comparable formula ok', so WIC can substitute an equivalent product if needed. The form also notes that powder formulas are not sterile, which matters when choosing a physical form.