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South Dakota WIC Medical Documentation Form

South Dakota WIC uses this two-page form, effective December 2022, to request exempt formulas, WIC-eligible nutritionals, standard formula for infants who can't tolerate solid foods, and supplemental food changes for patients with qualifying medical conditions. The provider completes sections A through D for every request. WIC dietitians review and fill it, and may ask for more documentation if a diagnosis is missing or inconsistent with growth data.

Who completes it

A licensed health care provider (MD, DO, CNP or PA) completes all four sections and signs and dates section D. If section C is left blank, the WIC dietitian or licensed nutritionist decides the supplemental foods.

Submitting and payment

How to submit it
Fax it to the WIC agency serving the participant or give it to the family to bring to WIC; the form points to the South Dakota WIC clinic directory for agency contacts.

Good to know

  • Prescribed amounts must be in ounces per day; ranges are allowed, but WIC maximum is accepted only for infants, and ad lib or as tolerated is not accepted.
  • Failure to thrive must meet a listed criterion, such as weight consistently below the 3rd percentile or less than 80% of ideal weight for height or age.
  • Enfamil Infant, Gentlease and ProSobee, standard Gerber formulas and store-brand formulas are listed as not allowed on this form.
  • A separate South Dakota WIC Health Data Form lets clinics share height, weight and hemoglobin without requesting formula.

Get the official form

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

Medical Documentation Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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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

How much formula can South Dakota WIC provide?

The form's table, based on 30 days a month, lists 27 to 29 fluid ounces a day for infants 0 to 3 months, 30 to 32 at 4 to 6 months, 21 to 23 at 6 to 11 months, and 30 ounces a day for children 12 months and older and women.

Does South Dakota WIC accept poor weight gain as a qualifying condition?

No. The form says weight gain, loss or maintenance does not qualify for WIC-issued medical formula, and neither do formula intolerance, spitting up, colic, or feeding difficulties without a medical diagnosis. Failure to thrive qualifies only if the patient meets at least one of the criteria on the back.

Can South Dakota WIC give whole milk to a 3-year-old?

Only if the child also receives a formula with a qualifying medical diagnosis. Section C lets the provider request whole milk for a child 2 or older or a woman; otherwise WIC regulations specify 1% or fat-free milk for those participants.