Nebraska WIC needs this authorization before it issues a specialty formula, whole milk after age 2 or 2% milk at age 1 to a child, or a specialized formula or whole milk to a pregnant, breastfeeding or postpartum woman. The provider records the diagnosis and growth data, the formula and amount, foods to withhold and the months requested. WIC cannot issue anything until every applicable section is complete.
A licensed provider (MD, DO, PA or NP) completes sections A through G, including the required diagnosis and clinical data, and signs or stamps section G. The WIC clinic fills in its contact block at the top and the approval line at the bottom.
Download the current version from the source each time; forms change without notice.
Provider Authorization Form For Specialty Formulas and WIC Supplemental Foods - Children and Women
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Yes, for children ages 1 to 5. Nebraska WIC's provider page says a PAF is needed for any contract or specialty formula on the Formulary for a child, and also for whole milk over age 2 or 2% milk at age 1. For infants, contract formulas need no PAF.
Section C notes that WIC provides approximately 29 ounces per day. Check maximum allowable or enter a specific number of ounces per day, and add any special instructions. If the child receives Medicaid, the form asks you to send the prescription to the Medicaid managed care organization instead.
Section G takes the signature or stamp of a health care provider with the credentials MD, DO, PA or NP, along with the date, printed name, phone and fax. WIC staff then record the participant's family ID, who approved the request and the approval date.