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Nebraska WIC Provider Authorization Form: Infants

Nebraska WIC uses this two-page authorization for infants up to 12 months who need a specialized or non-contract formula, or a change to the standard infant food package such as extra formula instead of solids. The provider enters the diagnosis, length and weight, formula and daily amount, readiness for foods and the months requested. Contract Similac formulas need no authorization.

Who completes it

The infant's licensed health care provider (MD, DO, PA or NP) completes sections A through F and signs or stamps section F. WIC staff fill in the clinic contact block and the approval line.

Submitting and payment

How to submit it
Fax it to the local WIC clinic listed at the top of the form, or give it to the parent to take to the WIC appointment.

Good to know

  • Section C shows what WIC provides: about 28 ounces a day from birth to 3 months, 30 ounces at 4 to 5 months and 22 ounces at 6 to 11 months.
  • Infants on both WIC and Medicaid receive specialty formula from Medicaid, according to Nebraska WIC's health care provider page.
  • Spitting up, colic, constipation, fussiness, gas, formula intolerance and parental preference do not qualify; these infants can receive the contract Similac formulas instead.
  • If section E is blank, WIC issues six months including the current month; if section D is blank, all infant foods are provided from 6 months.

Get the official form

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

Provider Authorization Form For Specialty Formulas and WIC Supplemental Foods - Infants up to 12 months

Official pagePDF

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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.

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Frequently asked questions

Which formulas need a Nebraska WIC infant PAF?

Any formula other than the standard contract formulas (Similac Advance, Soy Isomil, Sensitive and Gentle Comfort), plus specialized formulas and changes to the standard infant food package. Page 2 lists specialty infant formulas WIC provides with a qualifying condition, such as Alimentum, Nutramigen, Neocate Infant, EleCare Infant and NeoSure.

Can an infant over 6 months get more formula instead of baby food?

Yes, if the provider documents it. Section D asks whether the infant is not medically or developmentally ready for solid foods and needs additional formula. Answering yes replaces WIC infant cereal, fruits and vegetables with formula; leaving it blank means all age-appropriate foods are provided.

How long does a Nebraska WIC infant authorization last?

The provider chooses one to six months in section E. If nothing is marked, WIC issues six months, counting the current month. The form only covers infants up to 12 months; a child who still needs specialty formula after the first birthday is covered by the separate Children and Women form.