Hawaii WIC needs this form before it issues a non-contract formula to a participant with a qualifying medical condition or tailors their WIC foods. The provider completes sections A to D for every patient: diagnosis and how long the documentation is valid, formula and daily amount, supplemental foods and milk type, and signature. Page 2 lists approved formulas and their indications.
An MD, DO, NP or PA completes sections A to D and signs. WIC staff fill in the clinic contact details at the top and record who approved the request.
Download the current version from the source each time; forms change without notice.
Medical Documentation Form
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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Any non-contract formula, such as NeoSure or EnfaCare for prematurity, Nutramigen or Alimentum for protein allergy, amino acid formulas like EleCare or Neocate, Pregestimil, PM 60/40, Enfamil AR for diagnosed GERD, and pediatric formulas like PediaSure. Page 2 pairs each product with the condition WIC expects to see.
WIC provides whole milk for children 12 to 23 months and low-fat (1%) or nonfat milk for children over 2 and for women. The provider can select reduced-fat (2%) milk, or whole milk for those older groups when a formula is also prescribed.