Form DCH-1326 "Wic Special Formula/Food Request" - Michigan

What Is Form DCH-1326?

This is a legal form that was released by the Michigan Department of Health and Human Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DCH-1326 by clicking the link below or browse more documents and templates provided by the Michigan Department of Health and Human Services.

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Download Form DCH-1326 "Wic Special Formula/Food Request" - Michigan

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WIC SPECIAL FORMULA/FOOD REQUEST
Michigan Department of Health and Human Services
Please Complete ALL Sections (Section 4 is optional)
Client Name
Date of Birth
Parent/Guardian Name
Please specify the underlying qualifying condition below. Conditions such as rash, non-specific
intolerance, underweight, fussiness, colic, spitting-up, vomiting, gas and constipation will NOT be
considered indications for a special formula.
1. QUALIFYING MEDICAL CONDITION(S):
Preterm birth < 37 weeks gestation
Low birth weight (≤ 5 lbs 8 oz)
Failure to thrive
Severe food allergies (specify)
Immune system disorder (specify)
Metabolic disorder/inborn errors of metabolism (specify)
Medical condition that impairs nutrition status (specify)
Gastrointestinal disorder/malabsorption syndromes (specify)
2. FORMULA:
Select Amount Requested:
Ounces/day or
Maximum Allowable*
*WIC’s Maximum allowable may not meet patient’s full need.
Michigan Authorized Formula list is available at: www.michigan.gov/wic.
3. SUPPLEMENTAL FOODS:
All (issue all allowed age appropriate WIC Foods starting at six months)
For women/children > 12 months old: issue infant cereal & infant fruits/vegetables instead of
cereal, fruits/vegetables
Restriction (check foods to be OMITTED):
Infant (6-12 months)
Child (1-5 years) and Woman
All (issue formula only)
All (issue formula only)
Peanut Butter
Infant cereal
Milk
Breakfast cereal
Infant fruits/vegetables
Yogurt
Bread, rice, tortilla, oatmeal, pasta
Cheese
Fruits/vegetables
Eggs
100% fruit/vegetable juice
Legumes
Canned fish (women only)
Instructions/Comments:
4. MILK SUBSTITUTIONS (optional): Medical Reason:
Whole Milk (Honored only if medically indicated formula prescribed)
2% Milk (In place of < 1% milk, woman/child > 2 years; or whole milk, child 12-23 months)
Soy Beverage:
Milk allergy
Lactose intolerance
Cultural /Vegan diet
5. DURATION:
1 Mo
2 Mos
3 Mos
4 Mos
5 Mos
6 Mos (maximum)
6. Medical Provider Name
WIC Clinic Use Only
Address
Approved Through (optional)
Phone Number
Fax
Name
Phone Number
Signature
Date
Fax
Date
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any
individual or group because of race, religion, age, national origin, color, height, weight, marital status,
genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
This institution is an equal opportunity provider.
DCH-1326 (Rev. 9-20) Previous edition obsolete.
WIC SPECIAL FORMULA/FOOD REQUEST
Michigan Department of Health and Human Services
Please Complete ALL Sections (Section 4 is optional)
Client Name
Date of Birth
Parent/Guardian Name
Please specify the underlying qualifying condition below. Conditions such as rash, non-specific
intolerance, underweight, fussiness, colic, spitting-up, vomiting, gas and constipation will NOT be
considered indications for a special formula.
1. QUALIFYING MEDICAL CONDITION(S):
Preterm birth < 37 weeks gestation
Low birth weight (≤ 5 lbs 8 oz)
Failure to thrive
Severe food allergies (specify)
Immune system disorder (specify)
Metabolic disorder/inborn errors of metabolism (specify)
Medical condition that impairs nutrition status (specify)
Gastrointestinal disorder/malabsorption syndromes (specify)
2. FORMULA:
Select Amount Requested:
Ounces/day or
Maximum Allowable*
*WIC’s Maximum allowable may not meet patient’s full need.
Michigan Authorized Formula list is available at: www.michigan.gov/wic.
3. SUPPLEMENTAL FOODS:
All (issue all allowed age appropriate WIC Foods starting at six months)
For women/children > 12 months old: issue infant cereal & infant fruits/vegetables instead of
cereal, fruits/vegetables
Restriction (check foods to be OMITTED):
Infant (6-12 months)
Child (1-5 years) and Woman
All (issue formula only)
All (issue formula only)
Peanut Butter
Infant cereal
Milk
Breakfast cereal
Infant fruits/vegetables
Yogurt
Bread, rice, tortilla, oatmeal, pasta
Cheese
Fruits/vegetables
Eggs
100% fruit/vegetable juice
Legumes
Canned fish (women only)
Instructions/Comments:
4. MILK SUBSTITUTIONS (optional): Medical Reason:
Whole Milk (Honored only if medically indicated formula prescribed)
2% Milk (In place of < 1% milk, woman/child > 2 years; or whole milk, child 12-23 months)
Soy Beverage:
Milk allergy
Lactose intolerance
Cultural /Vegan diet
5. DURATION:
1 Mo
2 Mos
3 Mos
4 Mos
5 Mos
6 Mos (maximum)
6. Medical Provider Name
WIC Clinic Use Only
Address
Approved Through (optional)
Phone Number
Fax
Name
Phone Number
Signature
Date
Fax
Date
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any
individual or group because of race, religion, age, national origin, color, height, weight, marital status,
genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
This institution is an equal opportunity provider.
DCH-1326 (Rev. 9-20) Previous edition obsolete.