Virginia WIC uses the WIC-395 when a participant's diagnosed condition severely impairs ingestion, digestion, absorption or use of nutrients, or makes conventional foods inadequate, and a specialized formula is needed. The four-page file is a cover letter plus separate infant, child and woman pages. The provider completes sections A through D on the page for the participant's category, including an ICD-coded diagnosis and any food restrictions.
A health care provider authorized to write prescriptions under state law (MD, DO, PA or NP) completes every field in sections A to D and signs. WIC staff record approval, pending or denial details.
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Virginia WIC Request for Special Prescription
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It is the Virginia WIC Request for Special Prescription, which a provider uses to request specialized medical formula for a WIC participant. The file includes a cover letter and three versions, for infants, children and women, and requests must be submitted on the page for the participant's category.
Common reasons named in the cover letter include missing information, a non-qualifying condition such as colic, gas or picky eating, a diagnosis that doesn't fit the formula requested, or a non-contract brand like Enfamil. The letter notes that denial does not mean WIC staff question the provider's clinical judgment.
Each page offers a length of use from 1 to 6 months. On the infant page, the prescription cannot go past the infant's first birthday. If the participant needs more than one product, all of them must be listed on a single form.