WIC Formula and Medical Nutritional Prescriptions 2009 free printable template

WIC FORMULA and MEDICAL NUTRITIONAL PRESCRIPTIONS All components of this form are required and must be completed by a medical provider to receive Medically Prescribed Formulas through the WIC program.

How to fill out WIC Formula and Medical Nutritional Prescriptions

How to fill out WIC Formula and Medical Nutritional Prescriptions

1. Obtain the WIC Formula and Medical Nutritional Prescription form from your local WIC office or website.
2. Fill in the personal information section with the participant's name, date of birth, and WIC ID number.
3. Specify the medical condition or nutritional need in the designated section of the form.
4. Select the type of formula or nutritional product required based on the recommendations of a healthcare provider.
5. Indicate the quantity and frequency of formula/nutritional product needed.
6. Ensure you have the signature of a healthcare provider or WIC-authorized professional where required.
7. Submit the completed form to your local WIC office for review and approval.

Who needs WIC Formula and Medical Nutritional Prescriptions?

1. Infants and young children who have specific medical conditions or are at risk of malnutrition.
2. Pregnant and postpartum women needing nutritional support.
3. Individuals diagnosed with specific health issues that require specialized formulas or dietary supplements.

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What is WIC Formula and Medical Nutritional Prescriptions?

WIC Formula and Medical Nutritional Prescriptions are documents used in the Women, Infants, and Children (WIC) program to provide specific nutritional guidelines and options for participants who require specialized formulas or dietary plans due to health conditions.

Who is required to file WIC Formula and Medical Nutritional Prescriptions?

Healthcare providers, including physicians and dietitians, are required to file WIC Formula and Medical Nutritional Prescriptions on behalf of eligible participants who need specialized nutritional support.

How to fill out WIC Formula and Medical Nutritional Prescriptions?

To fill out WIC Formula and Medical Nutritional Prescriptions, providers must complete all required sections, including participant information, specific nutritional needs, and recommended formulas or dietary modifications, ensuring accuracy and clarity.

What is the purpose of WIC Formula and Medical Nutritional Prescriptions?

The purpose of WIC Formula and Medical Nutritional Prescriptions is to ensure that eligible individuals, especially infants and children, receive appropriate nutritional support that meets their health requirements.

What information must be reported on WIC Formula and Medical Nutritional Prescriptions?

The information that must be reported includes the participant’s name, date of birth, nutritional needs, specific formula or dietary requirements, duration of need, and the healthcare provider's details.