Form WIC-11 "Medical Documentation for Wic Formula and Approved Wic Foods for Infants, Children and Women" - New Jersey

What Is Form WIC-11?

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

Form Details:

  • Released on April 1, 2016;
  • The latest edition provided by the New Jersey Department of Health;
  • 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 WIC-11 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form WIC-11 "Medical Documentation for Wic Formula and Approved Wic Foods for Infants, Children and Women" - New Jersey

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New Jersey Department of Health
WIC Services
MEDICAL DOCUMENTATION FOR WIC FORMULA AND
APPROVED WIC FOODS FOR INFANTS, CHILDREN AND WOMEN
WIC Clinic
Phone
Fax
Please complete entire form. Fax the completed form to the WIC clinic or have your patient return the
document to the WIC Clinic. Thank you!
PLEASE NOTE: It is the responsibility of the health care provider to provide close medical oversight and instructions to
participants issued exempt infant formula, WIC-eligible Nutritionals and/or supplemental foods that require medical
documentation. This responsibility cannot be assumed by personnel at the WIC State or local agency.
Re-authorization is required every three months.
No authorization is necessary for Enfamil Infant, Enfamil Gentlease and Prosobee. Documentation for Enfamil AR
is requested, but not required.
Patient Name (First and Last)
Current Height/Length:
Date of Birth
Current Weight:
Parent/Caregiver Name (First and Last)
Date
1.
Formula Requested:
Amount Requested:
Maximum Allowable
OR
ounces/day (if formula)
Physical Form:
Powder
Concentrate
Intended Length of Use:
1 Month
2 Months
3 Months
2.
Qualifying Condition(s) (Justifies the medical need.)
(Complete and submit Page 2 with this form.)
3.
Can patient receive supplemental (or other WIC) foods in addition to formula or medical food?
Yes
No
(If Yes, please check the foods below that your patient CAN / IS eating.)
Infants (6-11 months only):
Infant Cereal
Infant Vegetable or Fruit
Children and Women:
Juice
Breakfast Cereal
Whole Wheat Bread or Other Whole Grains
Eggs
Vegetables and Fruits
Milk or Milk Substitutes
Legumes
Canned Fish*
Peanut Butter
Reasons/Instructions/Comments:
*Fully breastfeeding women, women partially breastfeeding multiple infants from the same pregnancy, women pregnant with
multiple infants, and pregnant women who are mostly breastfeeding an infant are the only WIC participant categories eligible
to receive these foods.
Health Care Provider Name (Print)
MD
DO
APN
PA-C
Medical Office/Clinic
Telephone Number
Medical Office/Clinic Address
Fax Number
Health Care Provider Signature
Date
WIC OFFICE USE ONLY:
Reviewed by CPA Name:
Date:
If required: MS and/or RD CPA Name:
Approved
# of months: _________
Disapproved
WIC-11
This institution is an equal opportunity provider.
http://www.nj.gov/health/fhs/wic
APR 16
Page 1 of 2 Pages.
New Jersey Department of Health
WIC Services
MEDICAL DOCUMENTATION FOR WIC FORMULA AND
APPROVED WIC FOODS FOR INFANTS, CHILDREN AND WOMEN
WIC Clinic
Phone
Fax
Please complete entire form. Fax the completed form to the WIC clinic or have your patient return the
document to the WIC Clinic. Thank you!
PLEASE NOTE: It is the responsibility of the health care provider to provide close medical oversight and instructions to
participants issued exempt infant formula, WIC-eligible Nutritionals and/or supplemental foods that require medical
documentation. This responsibility cannot be assumed by personnel at the WIC State or local agency.
Re-authorization is required every three months.
No authorization is necessary for Enfamil Infant, Enfamil Gentlease and Prosobee. Documentation for Enfamil AR
is requested, but not required.
Patient Name (First and Last)
Current Height/Length:
Date of Birth
Current Weight:
Parent/Caregiver Name (First and Last)
Date
1.
Formula Requested:
Amount Requested:
Maximum Allowable
OR
ounces/day (if formula)
Physical Form:
Powder
Concentrate
Intended Length of Use:
1 Month
2 Months
3 Months
2.
Qualifying Condition(s) (Justifies the medical need.)
(Complete and submit Page 2 with this form.)
3.
Can patient receive supplemental (or other WIC) foods in addition to formula or medical food?
Yes
No
(If Yes, please check the foods below that your patient CAN / IS eating.)
Infants (6-11 months only):
Infant Cereal
Infant Vegetable or Fruit
Children and Women:
Juice
Breakfast Cereal
Whole Wheat Bread or Other Whole Grains
Eggs
Vegetables and Fruits
Milk or Milk Substitutes
Legumes
Canned Fish*
Peanut Butter
Reasons/Instructions/Comments:
*Fully breastfeeding women, women partially breastfeeding multiple infants from the same pregnancy, women pregnant with
multiple infants, and pregnant women who are mostly breastfeeding an infant are the only WIC participant categories eligible
to receive these foods.
Health Care Provider Name (Print)
MD
DO
APN
PA-C
Medical Office/Clinic
Telephone Number
Medical Office/Clinic Address
Fax Number
Health Care Provider Signature
Date
WIC OFFICE USE ONLY:
Reviewed by CPA Name:
Date:
If required: MS and/or RD CPA Name:
Approved
# of months: _________
Disapproved
WIC-11
This institution is an equal opportunity provider.
http://www.nj.gov/health/fhs/wic
APR 16
Page 1 of 2 Pages.
MEDICAL DOCUMENTATION FOR WIC FORMULA AND
APPROVED WIC FOODS FOR INFANTS, CHILDREN AND WOMEN
QUALIFYING CONDITIONS
(Please check appropriate Qualifying Conditions.)
Participant
Non-Qualifying Conditions
Qualifying Conditions
Category
Infants
Severe food allergies
Non-specific formula or food
intolerance
(up to 12
Milk and soy allergies
months)
Only condition is a diagnosed
Metabolic disorders
formula intolerance or food allergy to
Gastrointestinal disorder
lactose, sucrose, milk protein or soy
Mal-absorption disorders
protein that does not require an
exempt infant formula
Premature birth
Failure to thrive/severely underweight
Low birth weight
NG/Tube Fed
Oral/motor feeding problems
Immune system disorders
Life threatening disorders
Children
Severe food allergies
Solely for the purpose of enhancing
nutrient intake or managing body
(up to five years
Milk and soy allergies
weight without an underlying
of age)
Metabolic disorders
condition
Gastrointestinal disorder
Lactose intolerance
Mal-absorption disorders
Participant preference
Premature birth
Failure to thrive/severely underweight
Low birth weight
NG/Tube Fed
Oral/motor feeding problems
Immune system disorders
Life threatening disorders
Women
Severe food allergies
Solely for the purpose of enhancing
nutrient intake or managing body
Milk and soy allergies
weight without an underlying
Metabolic disorders
condition
Gastrointestinal disorder
Lactose intolerance
Mal-absorption disorders
Participant preference
NG/Tube Fed
Oral/motor feeding problems
Immune system disorders
Life threatening disorders
WIC-11
APR 16
Page 2 of 2 Pages.
Page of 2