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Nevada WIC Medical Documentation Form (July 2024)

Nevada WIC uses this one-page form when a participant with a qualifying medical condition needs a special formula or nutritional instead of the standard Similac contract formulas, or needs changes to WIC foods. The provider picks the diagnosis, names the formula, form, daily amount and duration, and either lets the WIC nutritionist set supplemental foods or chooses them. The July 2024 version is fillable.

Who completes it

A health care provider must complete Parts A and B (condition and formula) and Section III, which needs an original signature; the name may be printed or stamped. In Part C the provider either authorizes the WIC nutritionist to decide supplemental foods or selects them.

Submitting and payment

How to submit it
Fax it to the participant's local WIC clinic or give it to the participant to bring to WIC.

Good to know

  • Nevada WIC cannot provide Enfamil Infant, Gentlease, Sensitive or ProSobee, the Enspire and NeuroPro lines, or several Similac and Gerber products, even with medical documentation.
  • Fussiness, colic, spitting up, gas, constipation, picky eating and milk or formula intolerance are not accepted diagnoses, and WIC won't give formula only to boost intake or manage weight.
  • Duration choices are 3 months, 6 months or until the infant turns 12 months old.
  • Low-fat milk for a child under 2, or whole milk for a woman or a child 2 and older, needs a medical diagnosis in Part A.

Get the official form

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

Nevada WIC Medical Documentation Form

Official pagePDF

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

Can I stamp my signature on the Nevada WIC Medical Documentation Form?

No. Section III allows the provider's name and office details to be printed or stamped, but it requires an original signature. Parts A and B, the qualifying condition and the formula request, must also be completed by the health care provider.

Which formulas will Nevada WIC not provide?

The form lists formulas Nevada WIC cannot provide even with medical documentation: Enfamil Infant, Gentlease, Sensitive and ProSobee, the Enfamil Enspire and NeuroPro lines, Similac 360 Total Care and Sensitive powder, Similac Pro-Total Comfort, and Gerber Good Start Gentle, Pro, SoothePro and Soy.

What happens if I let the WIC nutritionist decide foods?

Checking the first box in Part C authorizes the WIC nutritionist to set supplemental foods, amounts and timing based on the qualifying condition. If you decline, you choose the options yourself, such as formula only with no infant foods, baby foods for a child, or specific foods to omit.