GA Medical Documentation Form for WIC Special Formulas and WIC Foods 2016-2025 free printable template

1Georgia WIC Program Medical Documentation Form for WIC Special Formulas and WIC Foods Patients First & Last Name: Date of Birth (MM/DD/BY): Parent/Caregivers First & Last Name: 1. Qualifying Medical

How to fill out ga wic 2016-2025 form

How to fill out GA Medical Documentation Form for WIC Special Formulas

1. Obtain the GA Medical Documentation Form from the relevant WIC office or website.
2. Fill in the basic information, including the child's name, date of birth, and WIC ID number.
3. Indicate the specific medical condition that requires special formula on the form.
4. Provide detailed information regarding the recommended special formula, including the brand and type.
5. Include any pertinent medical history or notes from the healthcare provider.
6. Ensure that the form is signed and dated by the healthcare professional overseeing the child's care.
7. Submit the completed form to the WIC office for review and approval.

Who needs GA Medical Documentation Form for WIC Special Formulas?

1. Children who have specific medical conditions requiring special formulas, such as metabolic disorders, allergies, or other health issues.
2. Parents or guardians of eligible children enrolled in the WIC program who need assistance with specialized nutrition.

People Also Ask about

How many cans of formula does WIC give you in Maryland?

Up to 104 fl oz reconstituted powder can be issued only for qualifying conditions as listed in Policy and Procedure 5.09. 1 IBP-mostly applies to infants that are breastfed and are receiving <14 fl oz of formula from WIC.

How many cans of formula does WIC give you in Michigan?

Prior to one month of age, a partially breastfed infant shall only be issued one can of powder infant formula in the container size that provides closest to 104 reconstituted fluid ounces, to support exclusive breastfeeding.

What is the ICD-10 code for protein Allergy?

Food protein-induced enterocolitis syndrome 21 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2023 edition of ICD-10-CM K52. 21 became effective on October 1, 2022.

What is the ICD 10 code for Z91 011?

ICD-10 code Z91. 011 for Allergy to milk products is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

What is the differential diagnosis for milk protein Allergy?

Due to a wide variety of symptoms that can be caused by cow's milk allergy, the differential diagnosis can be extensive and include but not limited to: Other food allergies. Celiac disease. Enteropathy.

What is the ICD 10 code for milk protein allergy?

Z91. 011 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

What type of formula does WIC provide TN?

includes Human Milk Fortifier from Similac and Enfamil. TN WIC cannot provide any other brand of standard infant formula, such as Enfamil or Good Start products.

What are ICD 10 codes?

International Classification of Diseases, Tenth Revision (ICD-10) is a system used by physicians to classify and code all diagnoses, symptoms and procedures for claims processing.

What does the ICD 10 CM stand for?

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

What is the 5th character in the ICD 10 code?

All ICD-10-PCS codes are seven characters long, with the fifth character from the medical and surgical section identifying the approach. The approach is defined as the technique used to reach the site of the procedure. Approaches may be through the skin or mucous membrane, through an orifice or external.

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What is GA Medical Documentation Form for WIC Special Formulas?

The GA Medical Documentation Form for WIC Special Formulas is a required document for participants seeking approval for the use of special infant formulas under the Women, Infants, and Children (WIC) program in Georgia. It is used to provide necessary medical information supporting the need for special formulas.

Who is required to file GA Medical Documentation Form for WIC Special Formulas?

The GA Medical Documentation Form for WIC Special Formulas must be filed by healthcare providers or authorized professionals on behalf of WIC participants who require special formulas due to medical conditions or dietary restrictions.

How to fill out GA Medical Documentation Form for WIC Special Formulas?

To fill out the GA Medical Documentation Form, the healthcare provider should complete all sections of the form, including patient information, specific medical conditions, the recommended special formula, and a rationale for its use. The form must then be signed and dated by the healthcare provider.

What is the purpose of GA Medical Documentation Form for WIC Special Formulas?

The purpose of the GA Medical Documentation Form for WIC Special Formulas is to document the medical need for special formulas, ensuring that WIC participants receive appropriate nutrition based on their health requirements.

What information must be reported on GA Medical Documentation Form for WIC Special Formulas?

The form must report information including the participant's name, date of birth, medical diagnosis, justification for the use of special formula, type of formula requested, and the healthcare provider's signature and contact information.