West Virginia WIC uses the WIC-53 when a participant needs an exempt infant formula or WIC-eligible nutritional, or when a contract milk- or soy-based formula is prescribed for a child. Section A covers the formula, daily amount, diagnosis, form and time needed; Section B marks foods to withhold or stops supplemental foods entirely; Section C holds the prescriber's information and signature.
A medical professional (MD, DO, NP or PA) completes Section C and signs and dates it, along with Sections A and B as needed. WIC staff record who approved it.
Download the current version from the source each time; forms change without notice.
West Virginia WIC Program Prescription Formula Form for Prescribed Formulas and Foods
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Yes. The instructions for Section A say it covers prescribing a contract milk-based or soy-based infant formula to a child, as well as exempt formulas and WIC-eligible nutritionals. Include the diagnosis, the formula and an amount based on what the child currently drinks.
Section A offers time needed from one to six months. The form also asks you to mark whether the request is a formula change or a renewal of the most recent prescription, so continued use beyond six months goes on a renewal.
Yes. If a medical reason keeps the patient from eating foods beyond formula or a WIC-eligible nutritional, mark No supplemental foods at this time. Otherwise mark only the foods to exclude, and WIC provides the standard amount of everything else.