Virginia WIC Request for Special Prescription Form
The Virginia WIC Request for Special Prescription (WIC-395) Form is used by healthcare providers to request special nutritional products for women, infants, and children participating in the WIC program. This form requires detailed patient information and diagnoses based on Virginia WIC policy. Requests are subject to approval and must comply with program guidelines.
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How do I fill this out?
To fill out the Virginia WIC Request for Special Prescription Form, you will need to provide detailed patient information and medical data. Ensure all sections (A - E) are completed accurately. Be prepared to include ICD codes and specific diagnoses as required.
How to fill out the Virginia WIC Request for Special Prescription Form?
1
Collect all necessary patient data, including weight, height, and diagnosis.
2
Complete Sections A - E with accurate information.
3
Include specific ICD codes and medical justifications as needed.
4
Select the appropriate formula and indicate any restrictions.
5
Ensure the healthcare provider's information and signature are included.
Who needs the Virginia WIC Request for Special Prescription Form?
1
Healthcare providers requesting special nutritional products for WIC participants.
2
Parents or guardians of infants needing specific formula due to medical conditions.
3
Pregnant women with conditions requiring special dietary supplements.
4
Breastfeeding women requiring enhanced nutrition.
5
Infants and children with a diagnosis requiring additional nutritional support.
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1
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2
Use our PDF editor to fill out all required fields.
3
Add or modify text, select options, and include necessary information.
4
Review the form to ensure all sections are completed accurately.
5
Save and download the edited form for submission.
What are the instructions for submitting this form?
Submit the completed form to your local WIC office. Forms can be submitted via email, fax, or physical mail. Contact your local WIC office for specific submission details. Ensure all sections are completed accurately and include necessary medical justifications.
What are the important dates for this form in 2024 and 2025?
Ensure to check with the WIC program for specific submission deadlines relevant to your request in 2024 and 2025.
What is the purpose of this form?
The Virginia WIC Request for Special Prescription (WIC-395) Form is an essential document for healthcare providers seeking to provide special nutritional products to women, infants, and children in the WIC program. The form is used to request approval for special dietary supplements and nutritional products that meet specific medical needs. Accurate completion of the form ensures that participants receive the appropriate nutritional support in line with program guidelines.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes name, date of birth, guardian's name (for infants/children), and contact details.
- 2. Anthropometric Data: Requires recent weight and height measurements to be collected on the same date.
- 3. Formula Information: Lists requested products, medical justifications, daily amounts, and length of use.
- 4. Allowable WIC Foods: Indicates any restrictions or modifications to standard WIC foods.
- 5. Health Care Provider Information: Includes the provider's name, credentials, contact details, and signature.
What happens if I fail to submit this form?
Failure to submit the form may result in delays or denial of special nutritional products.
- Delayed Approval: Processing time may increase if the form is incomplete.
- Denial of Benefits: Incomplete or inaccurate forms may not be approved.
How do I know when to use this form?
- 1. Request Special Formula: For infants needing specific formula due to medical conditions.
- 2. Dietary Supplements: For pregnant or breastfeeding women needing special nutrition.
Frequently Asked Questions
What is the purpose of the Virginia WIC Request for Special Prescription Form?
The form is used by healthcare providers to request special nutritional products for women, infants, and children in the Virginia WIC program.
How do I fill out the Virginia WIC Request for Special Prescription Form?
Gather all necessary patient information, complete Sections A - E, include ICD codes, select appropriate formula, and ensure provider's signature.
Can I edit the form on PrintFriendly?
Yes, you can use PrintFriendly's PDF editor to fill out and modify the form.
How do I sign the form on PrintFriendly?
Use our electronic signature tool to add the authorized healthcare provider's signature.
Can I share the form directly from PrintFriendly?
Yes, you can share the completed form via email or generate a shareable link on PrintFriendly.
Who needs to fill out this form?
Healthcare providers and guardians requesting special nutritional products for WIC participants need to fill out this form.
What information is required on the form?
Patient information, anthropometric data, formula information, allowable foods, and healthcare provider details are required.
How often does this form need to be submitted?
The form should be submitted for each request for special nutritional products, as per medical and program guidelines.
Are there specific medical conditions that qualify for special prescriptions?
Yes, conditions such as low maternal weight gain, severe allergies, or special dietary needs qualify for special prescriptions.
How do I ensure my form is approved?
Ensure all required sections are completed accurately, include necessary ICD codes, and provide appropriate medical justifications.
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