Montana WIC uses this two-page prescription to issue medical formulas and nutritional products under Food Package III. Page 1 is the infant formula request and page 2 the child and adult request; on each, the provider picks the product, amount, length of time and diagnosis, then sets supplemental foods. All requests are subject to WIC staff approval.
The health care provider completes the sections and fills in printed name, signature, credentials and phone, all required. Infant requests need sections A, B, C or D, and E, and the child and adult page requires every section.
Download the current version from the source each time; forms change without notice.
WIC Infant Formula Request 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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Page 2 lists pediatric drinks such as PediaSure, Boost Kid Essentials and Nutren Junior, Kate Farms pediatric formulas, Compleat Pediatric, Nutramigen Toddler, amino acid formulas such as EleCare Junior and Neocate, peptide formulas such as Peptamen Junior, and adult Ensure or Boost Original. It also asks whether Medicaid is providing formula.
The full food package is issued. The supplemental foods section is still required: choose the full package with standard substitutions, defer to the local WIC registered dietitian, issue formula only for a 6 to 12 month old infant, or circle the foods to delete.