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CT WIC 400-11 Medical Documentation: Infants/Children

Connecticut WIC needs this form, with a nutrition-related ICD-10 code, before it authorizes special or exempt formula, Enfamil AR, or medically needed changes to an infant's or child's WIC foods. Standard Similac contract formulas don't need it. For patients also on HUSKY/Medicaid, the form supports continuity of care while HUSKY pays for the formula.

Who completes it

Only clinicians licensed to prescribe in Connecticut, an MD, APRN or PA, complete and sign it. WIC staff record the date received, whether the provider was contacted and the CPA signature.

Submitting and payment

How to submit it
Give the completed form to the parent to take to the local WIC program or fax it to the clinic serving the patient. Allow at least one week, preferably two, when a formula must be special ordered.

Good to know

  • Since December 1, 2021, HUSKY/Medicaid pays first for special formula for dually enrolled patients. Check the dual-enrollment box and also send the pharmacy a prescription with an allowable ICD-10 code.
  • Intolerance, fussiness, gas, spitting up, constipation and colic don't qualify. The form lists codes such as K21.9 for reflux, P07.30 for prematurity and R62.51 for failure to thrive.
  • Length of use is 1, 3, 6 or 12 months, and no prescription is valid beyond 12 months. Powder or concentrate is routine; ready-to-feed only in specific situations.
  • The form also documents whole milk for children 2 to 5 on high-calorie formula, or reduced-fat milk for children 12 to 23 months when overweight or obesity is a concern.

Get the official form

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

WIC Medical Documentation Form - Infants and Children

Official pagePDF

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

Is an electronic signature accepted on Connecticut's WIC 400-11?

Yes, if the form has been imported into the prescriber's EHR. Otherwise an original signature is required, with the name, office, phone and address printed or stamped. Signing verifies you have seen and evaluated the patient's feeding problems and determined there is a serious medical condition.

Does Connecticut WIC need a form for Enfamil AR?

Yes. Enfamil AR replaced Similac for Spit-Up after it was discontinued, and it requires documented gastroesophageal reflux or another ICD-10 code on the medical documentation form. The infant and child version has a dedicated checkbox for requesting Enfamil AR at 20 calories per ounce.

What does the 'Refer to WIC Nutrition Professional' line mean?

It is a required yes or no. Checking yes authorizes the WIC nutrition professional to make future decisions about the types and amounts of supplemental foods, while the provider keeps medical oversight. Foods that are contraindicated are checked separately in the list above it, with a line to explain limits on amounts.