PA WIC Program Formula Authorization Form 2016-2025 free printable template
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P&P 7.08 Attachment 5Pennsylvania WIC Program Formula Authorization Form Clients First & Last Rebirth Apparent/Caregiver's First & Last Name 1. Formula requested: Amount requested:oz/day (if formula)
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How to fill out pa wic form 2016-2025
How to fill out PA WIC Program Formula Authorization Form
01
Obtain the PA WIC Program Formula Authorization Form from your local WIC office or website.
02
Fill in the child's personal information, including name, date of birth, and WIC ID number.
03
Provide information about the parent or guardian, including name and contact details.
04
Specify the type of formula that is needed for the child, including any special dietary requirements.
05
Indicate the quantity and frequency of formula required.
06
Sign and date the form to certify that the information provided is accurate.
07
Submit the completed form to your local WIC office for approval.
Who needs PA WIC Program Formula Authorization Form?
01
Families with infants or children who have specific dietary needs related to nutrition.
02
Parents or guardians of children who require formula due to health conditions.
03
Participants in the PA WIC Program looking to obtain formula assistance.
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What is PA WIC Program Formula Authorization Form?
The PA WIC Program Formula Authorization Form is a document used by the Pennsylvania Women, Infants, and Children (WIC) program to authorize specific formulas for eligible participants.
Who is required to file PA WIC Program Formula Authorization Form?
The form is required to be filed by healthcare providers when recommending a specialized formula for WIC participants who have specific nutritional needs.
How to fill out PA WIC Program Formula Authorization Form?
To fill out the form, healthcare providers must provide patient information, the recommended formula, medical indicators, and their contact details before submitting it to the WIC program.
What is the purpose of PA WIC Program Formula Authorization Form?
The purpose of the form is to ensure that WIC participants receive appropriate and medically necessary formulas that cater to their specific dietary needs.
What information must be reported on PA WIC Program Formula Authorization Form?
The form must report the participant's name, date of birth, the medical reason for formula authorization, the specific formula recommended, and the healthcare provider's information.
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