New Jersey WIC requires this two-page form before it issues exempt infant formula, WIC-eligible nutritionals or foods that need medical documentation, such as whole milk for women and children over 2. The provider names the formula and an alternative, the amount, form and length of use, checks qualifying conditions on page 2, and marks which WIC foods the patient can eat. A WIC competent professional authority then approves or disapproves it.
The health care provider (MD, DO, APN or PA-C) completes the entire form, including page 2, and signs it. WIC staff complete the office-use box, with a second review by an MS or RD competent professional authority when required.
Download the current version from the source each time; forms change without notice.
Medical Documentation for WIC Formula and Approved WIC Foods for Infants, Children and Women
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The form states that updated medical documentation is required every three months. You can still mark an intended length of use of 1, 2, 3 or 6 months in section 1, but the WIC office will expect new documentation from the provider at three months for continued formula.
Page 2 lists qualifying conditions by category, including severe food allergies, milk and soy allergies, metabolic, gastrointestinal and malabsorption disorders, prematurity, low birth weight, failure to thrive and tube feeding. Nonspecific formula intolerance, lactose intolerance, participant preference and enhancing nutrient intake without an underlying condition do not qualify.
Only with medical documentation on the WIC-11. Whole milk appears under physical form for women and children over 2, and page 2 lists unintended weight loss as a qualifying condition for whole milk for children, and underweight or maternal weight loss or inadequate gain for women.