Vermont WIC uses this fillable Word form when an infant or child needs a medical formula or medical food, or any standard formula after the first birthday. The provider gives the product, form, daily amount, length of use and an ICD-10 diagnosis, marks WIC foods that aren't allowed, and can request extra formula instead of infant foods, low-fat milk at 12 to 24 months, or infant foods after age 1.
A physician, physician assistant or APRN licensed to prescribe in Vermont completes and signs it, confirming they have evaluated the patient's feeding problems and symptoms. WIC staff review it for completeness and sign.
Download the current version from the source each time; forms change without notice.
Medical Documentation form for Infants and Children
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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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Infant documentation stays in effect until the baby turns 1. If the child still needs medical or standard formula after age 1, a new form is required, and children on long-term products such as PKU formula need updated documentation every year.
Yes, for medical formula requests. The form lists diagnoses with codes, such as food allergy Z91.01, failure to thrive R62.51, gastroesophageal reflux K21.9, neonatal abstinence syndrome P96.1 and preterm birth P07.30, plus an Other line for any qualifying diagnosis and its ICD-10 code.
Yes, on request. Whole milk is the standard issuance for children 12 to 24 months, but the provider can check the box asking WIC to provide low-fat or skim milk for a child in that age range.