Medical Documentation for WIC Special Formulas and Foods
This file is used by healthcare providers to authorize special formulas and WIC supplemental food for women, infants, and children with qualifying medical conditions. The form ensures that special formulas for non-specific symptoms are not issued. It includes sections for participant information, special formula requests, and healthcare provider details.
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How do I fill this out?
To fill this form, you will need to provide specific information about the participant and their medical condition. Ensure that all required fields are completed accurately. A healthcare provider must authorize the form with their signature.
How to fill out the Medical Documentation for WIC Special Formulas and Foods?
1
Enter participant information including name and date of birth.
2
Specify the special formula requested and required specifications.
3
Indicate the approval length and provide any necessary mixing instructions.
4
Fill out the healthcare provider information and obtain the provider's signature.
5
Submit the form to the appropriate WIC agency for approval.
Who needs the Medical Documentation for WIC Special Formulas and Foods?
1
Healthcare providers authorizing special formulas for WIC participants with medical conditions.
2
Parents or caregivers of infants and children requiring special formulas due to medical conditions.
3
WIC agencies processing requests for special formulas and supplemental foods.
4
Dietitians and nutritionists managing nutritional plans for WIC participants.
5
Individuals responsible for submitting medical documentation for WIC benefits.
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Review the form to ensure all sections are complete.
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What are the instructions for submitting this form?
Submit the completed form to your local WIC agency by mail, fax, or in-person. Ensure all required fields are filled and signed by a licensed healthcare provider. Contact your local WIC agency for specific submission guidelines and addresses.
What are the important dates for this form in 2024 and 2025?
The form is effective from October 1, 2014, and must be submitted based on the approval length specified, which can range from 1 to 6 months.
What is the purpose of this form?
The purpose of this form is to provide medical documentation required for issuing special formulas and WIC supplemental foods to participants with qualifying medical conditions. It ensures compliance with federal regulations and prevents unauthorized issuance of special formulas. Healthcare providers use this form to diagnose, prescribe, and authorize the appropriate nutritional support for WIC participants.
Tell me about this form and its components and fields line-by-line.
- 1. Participant Information: Includes participant's name, date of birth, and caregiver's name.
- 2. Special Formula: Details requested formula, required concentration, and daily amount.
- 3. Approval Length: Specifies the duration for which the formula is approved.
- 4. Medical Conditions: Provides areas to describe specific medical conditions.
- 5. WIC Supplemental Food: Lists WIC food items to be provided or omitted.
- 6. Healthcare Provider Information: Includes provider's name, contact information, and signature.
- 7. WIC Use Only: Marks whether the form is approved or disapproved and contains agency details.
What happens if I fail to submit this form?
Failure to submit the form can result in the denial of special formulas and supplemental foods for the participant.
- Denial of Benefits: Without proper documentation, WIC participants may not receive necessary nutritional support.
- Medical Risks: Participants with specific medical conditions might face health risks without prescribed formulas.
How do I know when to use this form?
- 1. Medical Conditions: For participants diagnosed with conditions like metabolic disorders or severe food allergies.
- 2. Low Birth Weight: For infants born with low birth weight requiring special nutritional support.
- 3. Premature Infants: For premature infants needing specific formulas to support growth.
- 4. Gastrointestinal Disorders: For participants with gastrointestinal issues requiring special formulas.
- 5. Whole Milk Issuance: For participants over 24 months old needing whole milk due to medical conditions.
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