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Patients Name: ___ Date of Birth: ___/___/___Parent or Guardians name: ___Request for Medical Formula or Medical Food: To request medical formula, or to request any standard infant formula for a child older than 12 months, provide the following information:Product requested: ___Product form: Powder Concentrate Ready to FeedPrescribed ounces per day*:___ OR ad libLength of use:Infants: ___ months OR Until Age 1 Children: ___ months OR For 1 year (new form required each year)
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How to fill out wic-400-11-medical-documentation-form--infants - ctgov

01
Obtain the WIC-400-11 Medical Documentation Form from your local WIC office or website.
02
Fill in the infant's name, date of birth, and other identifying information at the top of the form.
03
Provide information about the infant’s medical history, including any significant health conditions.
04
Document the infant's growth parameters such as weight, length, and head circumference.
05
Include any allergies or dietary restrictions that the infant may have.
06
Have a qualified healthcare provider sign and date the form to certify the information provided.
07
Submit the completed form to your local WIC office for processing.

Who needs wic-400-11-medical-documentation-form--infants - ctgov?

01
Infants who are applying for WIC benefits and require nutritional support.
02
Parents or guardians of infants who need to document health concerns to qualify for WIC assistance.

What is WIC-400-11-Medical-Documentation---Infants ... - CT.gov Form?

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The WIC-400-11 Medical Documentation Form for Infants is a document used in the Women, Infants, and Children (WIC) program to gather medical information relevant to the health and nutritional needs of infants participating in the program.
Healthcare providers who assess the health and nutrition of infants within the WIC program are required to file the WIC-400-11 Medical Documentation Form.
To fill out the WIC-400-11 Medical Documentation Form, healthcare providers need to complete sections that include the infant's medical history, current health status, and any relevant dietary needs. The form should be filled out accurately and in accordance with WIC guidelines.
The purpose of the WIC-400-11 Medical Documentation Form is to ensure that infants enrolled in the WIC program receive appropriate nutritional support based on their individual health and medical needs.
The information that must be reported on the WIC-400-11 Medical Documentation Form includes the infant's medical history, growth measurements, any diagnosed medical conditions, and recommendations for nutritional interventions.
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