North Carolina WIC requires this documentation before it issues exempt infant formula, WIC-eligible nutritionals or non-contract formula, or modifies WIC foods, for a participant with a qualifying medical condition. The prescriber records the diagnosis or ICD-10 code, the product, amount and duration, and any foods to omit, as federal WIC rules at 7 CFR 246.10(d) require.
A licensed provider with prescriptive authority, such as an MD, DO, NP or PA, completes the whole form and signs it.
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NC WIC Program Medical Documentation
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The qualifying medical diagnosis or ICD-10 code, the formula or nutritional product requested, the daily amount, how long it's needed, any WIC foods to omit, and the prescriber's signature. Federal WIC rules require this documentation before exempt formula or WIC-eligible nutritionals can be issued.
NC DHHS links it from the WIC health care provider resources page of its Community Nutrition Services Section, next to the exempt infant formulas and WIC-eligible nutritionals list, the Exchange of Information form and the online families referral form.