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Save As Print Form Georgia WIC Program Medical Documentation Form for WIC Special Formulas and Approved WIC Foods Patient's First & Last Name: Date of Birth (MM/DD/BY): Parent/Caregiver's First &

How to fill out georgia wic icd10 codes

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

1. Begin by downloading the GA Medical Documentation Form for WIC Special Formulas from the WIC website.
2. Fill out the necessary identifying information at the top of the form, including the child's name, date of birth, and WIC ID number.
3. Specify the type of special formula required in the designated section, including any specific brand or type as recommended by a healthcare provider.
4. Enter the medical condition that necessitates the use of the special formula in the provided field.
5. Include the healthcare provider's information, including name, contact number, and signature.
6. Review the completed form for accuracy and completeness before submission.
7. Submit the form to your local WIC office along with any other required documentation.

Who needs GA Medical Documentation Form for WIC Special Formulas?

1. The GA Medical Documentation Form for WIC Special Formulas is needed by infants and children who have specific medical conditions that require the use of special infant formulas, as determined by a healthcare provider.

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 document used to authorize and provide medical justification for the issuance of special formulas to clients participating in the WIC program.

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

Health care providers, such as doctors or registered dietitians, are required to file the GA Medical Documentation Form for WIC Special Formulas on behalf of eligible clients.

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

To fill out the GA Medical Documentation Form for WIC Special Formulas, the health care provider must provide the recipient's information, specify the medical needs for the special formula, and include the specific formula to be provided.

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 ensure that individuals who have specific medical needs are provided with appropriate nutritional support through special formulas funded by the WIC program.

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

The information that must be reported on the GA Medical Documentation Form includes the client's personal information, medical diagnosis, the reason for the special formula request, and the specific type of formula needed.