Arkansas WIC uses this one-page form to authorize special formulas, medical foods and food package changes that federal rules allow only with medical documentation. The prescriber picks the formula from a checklist, states the qualifying condition, amount and length of issuance, and notes any food restrictions. A WIC registered dietitian approves the request under program policy.
An MD, DO, APRN or PA completes sections A to D (items 1 to 15) and signs. WIC staff fill in the household ID, CPA name, approving dietitian, and start and expiration dates.
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Medical Documentation Form
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Section D lists MD, DO, APRN and PA as the credentials, with the provider's name, signature, phone and date. Every request is subject to approval by a WIC registered dietitian, who records whether it is approved or a renewal, the approved formula and amount, and the start and expiration dates.
The checklist groups products into prematurity formulas (EnfaCare, NeoSure), oral supplements and tube feedings such as Boost Kid Essentials and Peptamen Jr., extensively hydrolyzed formulas (Nutramigen, Alimentum, Pregestimil), amino acid based, specialized formulas such as PM 60/40, and metabolic formulas written in by name.