Oklahoma WIC participants who need a non-contract formula, or changes to their WIC foods, need this exception request from their provider. The form covers the qualifying diagnosis or ICD-10 code, the formula and daily amount, whether a comparable formula is acceptable, contraindicated foods and the length of issuance. WIC staff approve or deny it, and page 2 (351 K39a) lists example diagnoses and comparable formulas.
The health care provider completes all applicable sections and signs section 6, marking MD, DO, PA or APRN. WIC staff complete the approval box.
Download the current version from the source each time; forms change without notice.
Oklahoma WIC Exception Request for Formula/Food
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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Oklahoma WIC's health partners page names three common reasons: the form was missing information, the formula requested is not allowable for the diagnosis or ICD codes given, or the request was for a standard milk- or soy-based formula outside the WIC contract.
Section 6 accepts the signature of an MD, DO, PA or APRN, with the provider's printed name, the date, and phone and fax numbers. The provider information section is marked required, as is the medical reason in section 2.
It tells WIC whether it may issue an equivalent product if the requested formula is unavailable because of a recall or supply chain disruption. Page 2 gives examples, such as hypoallergenic formulas like Alimentum, Nutramigen or Pregestimil, and premature formulas like EnfaCare or NeoSure.