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Michigan WIC Special Formula/Food Request Form Client: DOB: Parent/Guardian: 1. QUALIFYING MEDICAL CONDITION(S): Conditions such as rash, non-specific intolerance, Premature birth 37 weeks gestation
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How to fill out wic application form
How to fill out wic formula request form:
01
Obtain the form from your local WIC office or download it from the official WIC website.
02
Fill in your personal information such as name, address, contact number, and date of birth.
03
Provide proof of income, which may include paycheck stubs, tax returns, or eligibility letters from other government assistance programs.
04
Fill in your household information, including the names and ages of all household members.
05
Indicate whether you are requesting a change in the type or brand of formula or if you need a specific type of formula due to a medical condition.
06
If applicable, provide supporting documentation, such as a letter from a healthcare professional, that explains the need for a specific type of formula.
07
Sign and date the form, attesting to the accuracy of the information provided.
08
Submit the completed form to your local WIC office or follow the instructions for submitting the form online, if available.
Who needs wic formula request form:
01
Pregnant women who are eligible for the Women, Infants, and Children (WIC) program and require formula for themselves or their unborn child.
02
New mothers who are eligible for the WIC program and need formula for their infant.
03
Caregivers or legal guardians of infants who are eligible for the WIC program and require formula for the child in their care.
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What is wic formula request form?
The WIC formula request form is a document used by healthcare providers to request specific infant formula for participants enrolled in the Women, Infants, and Children (WIC) program. It is used to ensure that infants who have unique dietary needs receive appropriate nutrition.
Who is required to file wic formula request form?
Healthcare providers, including doctors or dietitians, are required to file the WIC formula request form on behalf of eligible infants who require specialized formula due to medical conditions or dietary restrictions.
How to fill out wic formula request form?
To fill out the WIC formula request form, providers should include the infant's details, specify the type of formula required, outline the medical justification for the request, and ensure that all sections of the form are completed accurately before submitting it to the WIC program.
What is the purpose of wic formula request form?
The purpose of the WIC formula request form is to document and facilitate the provision of medically necessary infant formula to eligible participants in the WIC program, ensuring that infants receive proper nutrition based on their health needs.
What information must be reported on wic formula request form?
The WIC formula request form must report information including the infant's name, date of birth, medical diagnosis, the specific formula requested, duration of need, and the healthcare provider's details who is recommending the formula.
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