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CT WIC 400-11 Medical Documentation Form: Women

Connecticut WIC requires this form before it provides special or exempt formula, whole milk or medically restricted foods to a woman enrolled in WIC. The prescriber documents a serious qualifying condition with an ICD-10 code, the formula and its preparation, and the foods to withhold. WIC re-evaluates the continued need for formula periodically.

Who completes it

An MD, APRN or PA licensed to prescribe in Connecticut completes and signs it with an original signature. The WIC nutritionist records the date received, whether the provider was contacted, and signs.

Submitting and payment

How to submit it
Give the completed form to the patient to take to her local WIC program or fax it to the WIC clinic serving her.

Good to know

  • Listed codes include Z91.01 food allergy status, O24.01 pre-existing type 1 diabetes in pregnancy, O26.10 low weight gain in pregnancy and O30.90 multiple gestation. The patient must have a diagnosis, not symptoms.
  • For women also on HUSKY/Medicaid, check the dual-enrollment box and send a separate prescription with an allowable ICD-10 code to the pharmacy. WIC still needs this form.
  • Length of use choices are 1, 3 or 6 months. Women on formula get reduced-fat milk unless whole milk is documented for a condition needing high-calorie formula.
  • If only the amounts of supplemental foods need limits, check the restriction box and explain. Prescription renewal is required periodically, based on the medical condition.

Get the official form

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

WIC Medical Documentation Form - Women

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

Can the WIC nutritionist choose foods for a woman on special formula in Connecticut?

Yes, if you check yes on the required referral line. That authorizes the WIC nutrition professional to make future decisions about the types and amounts of WIC supplemental foods. Foods contraindicated by the diagnosis are checked separately, such as milk, cheese, eggs, legumes, peanut butter or juice.

Where are the HUSKY ICD-10 codes for adults listed?

The women's form links the Connecticut DSS list of enteral nutrition diagnosis codes for ages 21 and older on the ctdssmap.com portal. A pharmacy prescription carrying one of those codes is what lets HUSKY/Medicaid cover the product for a patient enrolled in both programs.