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Louisiana WIC-48 Medical Request for Formula/Food

Louisiana WIC requires this request before it issues exempt infant formula or WIC-eligible nutritionals, or restricts a participant's WIC foods. The provider records growth data, the formula chosen from the list on the back, a qualifying diagnosis, amount, duration and food restrictions. All requests are subject to WIC approval under program policies and procedures.

Who completes it

A medical provider (MD, DO, PA or CNP) completes all sections, prints their name, and signs and dates the form.

Submitting and payment

How to submit it
Return the form to the participant's WIC clinic by email or fax, or give it to the participant to upload in the myWIC app. The signed, dated request must be less than 60 days old when the clinic receives it.

Good to know

  • Constipation, diarrhea, unconfirmed allergies, milk protein or soy allergy, weight management, lactose intolerance and growth concerns are not allowed unless an underlying medical condition is present.
  • Duration is 1, 3 or 6 months, since federal guidelines cap issuance without renewal at 6 months. Slow growth and low birth weight apply only to infants under 6 months.
  • If an approved WIC-48 runs past the 6-month birthday and infant cereal or fruits and vegetables were omitted, a new WIC-48 is needed before those foods are issued.
  • Ready-to-feed requires a qualifying justification. Louisiana's formula contract is with Abbott, and the list on the back shows which products need a prescription.

Get the official form

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

Louisiana Medical Request for Formula and/or Food

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

Does milk protein allergy qualify on the Louisiana WIC-48?

Not by itself, because standard soy formula is available without a prescription. Louisiana WIC may approve it when the provider documents it in writing along with other conditions, such as diarrhea, severe allergies or GERD. Allergies must be confirmed by the medical provider; self-reported allergies do not qualify.

Must the provider decide on infant foods at 6 months on the WIC-48?

Yes. The provider must check whether to include or omit infant cereal and infant fruits and vegetables, and WIC staff should not assume these foods start at 6 months if nothing is marked. Infants who can't yet eat solids can be given formula only after 6 months.