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Vermont WIC Medical Documentation Form: Women

Vermont WIC needs this form when a pregnant, postpartum or breastfeeding woman requires a WIC-eligible formula or specialized nutrition product. The provider selects the qualifying diagnosis with its ICD-10 code, names the product, daily amount and form, sets the length of use for pregnancy or the postpartum period, and marks any WIC foods the diagnosis rules out. The fillable PDF dates from February 2018.

Who completes it

A physician, physician assistant or APRN licensed to prescribe in Vermont completes items 1 to 6 and signs, confirming they have seen the patient and found a serious medical condition. WIC staff review the form and sign it.

Submitting and payment

How to submit it
Give the completed form to the patient to take to her local WIC program, or fax or mail it to the WIC office serving her.

Good to know

  • Listed diagnoses include low weight gain in pregnancy (O26.1), adult failure to thrive (R62.7), lactose intolerance (E73), food allergy (Z91.01) and malabsorption syndromes (K90).
  • WIC is supplemental and may not supply the full amount prescribed; it routinely issues powder or concentrate and allows ready-to-feed only in limited situations.
  • Checking item 5 lets the WIC nutrition professional decide future supplemental foods; that authorization never covers the formula or medical food itself.
  • Vermont WIC also offers an online Provider Referral form for sending a patient to WIC.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Documentation for WIC Formula and Approved WIC Foods - Women

Official pagePDF

How this list is checked

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.

Frequently asked questions

Who can sign Vermont WIC's medical documentation form for women?

Only health care providers licensed to write prescriptions in Vermont: a physician, physician assistant or advanced practice registered nurse. Print or stamp your name, office, phone and address. Your signature verifies that you have seen and evaluated the patient's nutritional needs and found a serious medical condition.

How long does Vermont WIC formula documentation last for a pregnant patient?

Item 3 sets the length of use as during pregnancy or during the postpartum or breastfeeding period. WIC policy is to re-evaluate the participant's continued need for the formula periodically, and a renewal may be required depending on the medical condition.

Does the Vermont WIC women's form cover food restrictions?

Yes. Item 4 lets you mark all foods allowed or list contraindicated foods, such as dairy products, eggs, peanut butter, soy products, juice or canned fish. The patient receives the other supplemental foods for her category in addition to the formula.