Idaho WIC uses this form when a patient needs a non-standard formula, exempt infant formula or WIC-eligible nutritional, or medically needed changes to WIC foods. Federal WIC rules at 7 CFR 246.10 require this medical documentation before such products are issued. The prescriber records the diagnosis or ICD-10 code, product, amount, duration and any foods to omit.
A licensed provider with prescriptive authority, such as an MD, DO, NP or PA, completes the whole form and signs it.
Download the current version from the source each time; forms change without notice.
Medical documentation: WIC-eligible nutritionals and therapeutic formula
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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Yes. The Idaho WIC Partners page posts a video on completing the medical documentation form, aimed at health care providers, alongside the form itself. The same page links the formula handbook resources, including the product guide and instructions for searching it.
Any participant who needs a formula other than the standard WIC formula, an exempt infant formula or a WIC-eligible nutritional for a qualifying medical condition, and anyone whose WIC foods must change for medical reasons. Under 7 CFR 246.10, WIC issues these only with medical documentation from a prescriber.