Tennessee WIC uses this one-page request when a participant with a qualifying condition needs a therapeutic formula or WIC-eligible nutritional, along with any changes to supplemental foods. The provider names the formula, the months of issuance and the daily amount, checks the qualifying condition, and can omit foods or request whole or 2% milk with a medical reason. Every request is subject to WIC approval.
A provider (MD, DO, PA-C or NP) completes the required patient, formula and diagnosis sections and signs or stamps the form. If the food section is left blank, the WIC competent professional authority decides the foods.
Download the current version from the source each time; forms change without notice.
Request for WIC Therapeutic Products and Supplemental Foods
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The form lists maximum program amounts for fully formula-fed infants: 26 fluid ounces a day from 0 to 3 months, 29 at 4 to 5 months and 20 at 6 to 12 months. An infant 6 months or older who can't take solids can get formula only, up to 29 ounces a day.
Up to 6 months. You enter the requested length of issuance in months, and the form states that the formula can only be issued for up to 6 months and that the documentation needs to be updated every six months.
Tennessee WIC says select pharmacy locations provide therapeutic formulas for participants with specific needs, and pharmacies are authorized to accept TNWIC EBT cards for specialized infant formulas and other WIC-eligible nutritionals.