"Medical Documentation Form for Wic Special Formulas and Wic Foods" - Georgia (United States)

Medical Documentation Form for Wic Special Formulas and Wic Foods is a legal document that was released by the Georgia Department of Public Health - a government authority operating within Georgia (United States).

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1
Georgia WIC Program
Medical Documentation Form for WIC Special Formulas and WIC Foods
Patient’s First & Last Name: ________________________________________ Date of Birth (MM/DD/YY): ____/____/____
Parent/Caregiver’s First & Last Name: ___________________________________________________________________
1. Qualifying Medical Condition(s)
List the SPECIFIC diagnosed or suspected medical condition(s) and the ICD-9 or ICD-10 code(s) justifying the formula/medical
food prescription.
Qualifying diagnosed medical condition(s): __________________________________________________________________
And applicable ICD-9 or ICD-10 code(s): ___________________________________________________________________
Note: WIC approval and provision of prescription formulas and medical foods are based on Georgia WIC Program policies and procedures.
2. Special Formula Requested
Name of formula/medical food requested: ___________________________________________________________________
Prescribed ounces per day: _______________ oz/day*
Form:  Powder
 Concentrate
 Ready-to-feed
Special instructions/comments**: __________________________________________________________________________
Flavor: ____________________________________
With Fiber: Yes  No 
N/A
If Applicable:
Planned length of use: ___________ months
WIC prescription renewal is required periodically (every 1-6 months).
*
Prescribed amount per day is based on reconstituted fluid ounces of the formula product at standard dilution. Instructions on reverse.
**Prematurity: **: With documentation, premature infants can receive infant formula past one year to account for adjusted age. Medical
documentation will need to be provided at the one year WIC certification.
The use of ready-to-feed products requires additional justification for WIC unless ready-to-feed is the only available product form.
3. WIC Foods
Please complete section A or section B below. The patient may receive the supplemental foods – appropriate to his or her
WIC participant category – listed below in addition to the approved special formula.
A.
No Supplemental Food Restrictions: ___________ (provider initials)
If there are
prescribed food restrictions, please initial the “No Supplemental Food Restrictions” line above.
no
If there are prescribed food restrictions due to the patient’s medical condition(s):
B.
In the “Contraindicated Supplemental Foods” column, please check (
) any supplemental foods that
be issued
cannot
due to the patient’s medical condition(s). Please describe any other prescribed restrictions or special requests in the
“Comments” section below. (Developmental readiness, allergies, tube fed, NPO, etc.)
WIC Category
NOT
Contraindicated Supplemental Foods – Check the foods that should
be issued to the patient.
Infants
Infant Cereal
Baby Food Fruits and Vegetables
(6-11 mos.)
Milk
Beans / Peas
Vegetables / Fruits
Whole Grains (wheat bread,
Children (≥ 12 mos.)
rice, or whole grain tortillas)
Cheese
Peanut Butter
Juice
& Women
Cereal
Eggs
Canned Fish*
Comments:
* Only for exclusively breastfeeding women, women pregnant with multiple fetuses, and women mostly breastfeeding multiple infants.
4. Health Care Provider Information (Please Complete All Boxes.)
Provider’s Signature/Credentials:
*Title:
/
/
Provider’s Name (Please Print):
Date:
Original signature required. No stamped signatures or
proxy signatures (e.g., by nursing staff) will be accepted.
Medical Office/Clinic Name:
*Note: The Georgia WIC Program only accepts
Street Address:
prescriptions authorized and signed by the following
City:
providers:
Zip Code:
Physicians (MD, DO)
Phone Number:
Physician Assistants (PA, PA-C)
Fax Number:
Nurse Practitioners (e.g., NP, APRN, CPNP,
CNP, PNP, CNNP)
Page 1 of 2
Revised June 2012
1
Georgia WIC Program
Medical Documentation Form for WIC Special Formulas and WIC Foods
Patient’s First & Last Name: ________________________________________ Date of Birth (MM/DD/YY): ____/____/____
Parent/Caregiver’s First & Last Name: ___________________________________________________________________
1. Qualifying Medical Condition(s)
List the SPECIFIC diagnosed or suspected medical condition(s) and the ICD-9 or ICD-10 code(s) justifying the formula/medical
food prescription.
Qualifying diagnosed medical condition(s): __________________________________________________________________
And applicable ICD-9 or ICD-10 code(s): ___________________________________________________________________
Note: WIC approval and provision of prescription formulas and medical foods are based on Georgia WIC Program policies and procedures.
2. Special Formula Requested
Name of formula/medical food requested: ___________________________________________________________________
Prescribed ounces per day: _______________ oz/day*
Form:  Powder
 Concentrate
 Ready-to-feed
Special instructions/comments**: __________________________________________________________________________
Flavor: ____________________________________
With Fiber: Yes  No 
N/A
If Applicable:
Planned length of use: ___________ months
WIC prescription renewal is required periodically (every 1-6 months).
*
Prescribed amount per day is based on reconstituted fluid ounces of the formula product at standard dilution. Instructions on reverse.
**Prematurity: **: With documentation, premature infants can receive infant formula past one year to account for adjusted age. Medical
documentation will need to be provided at the one year WIC certification.
The use of ready-to-feed products requires additional justification for WIC unless ready-to-feed is the only available product form.
3. WIC Foods
Please complete section A or section B below. The patient may receive the supplemental foods – appropriate to his or her
WIC participant category – listed below in addition to the approved special formula.
A.
No Supplemental Food Restrictions: ___________ (provider initials)
If there are
prescribed food restrictions, please initial the “No Supplemental Food Restrictions” line above.
no
If there are prescribed food restrictions due to the patient’s medical condition(s):
B.
In the “Contraindicated Supplemental Foods” column, please check (
) any supplemental foods that
be issued
cannot
due to the patient’s medical condition(s). Please describe any other prescribed restrictions or special requests in the
“Comments” section below. (Developmental readiness, allergies, tube fed, NPO, etc.)
WIC Category
NOT
Contraindicated Supplemental Foods – Check the foods that should
be issued to the patient.
Infants
Infant Cereal
Baby Food Fruits and Vegetables
(6-11 mos.)
Milk
Beans / Peas
Vegetables / Fruits
Whole Grains (wheat bread,
Children (≥ 12 mos.)
rice, or whole grain tortillas)
Cheese
Peanut Butter
Juice
& Women
Cereal
Eggs
Canned Fish*
Comments:
* Only for exclusively breastfeeding women, women pregnant with multiple fetuses, and women mostly breastfeeding multiple infants.
4. Health Care Provider Information (Please Complete All Boxes.)
Provider’s Signature/Credentials:
*Title:
/
/
Provider’s Name (Please Print):
Date:
Original signature required. No stamped signatures or
proxy signatures (e.g., by nursing staff) will be accepted.
Medical Office/Clinic Name:
*Note: The Georgia WIC Program only accepts
Street Address:
prescriptions authorized and signed by the following
City:
providers:
Zip Code:
Physicians (MD, DO)
Phone Number:
Physician Assistants (PA, PA-C)
Fax Number:
Nurse Practitioners (e.g., NP, APRN, CPNP,
CNP, PNP, CNNP)
Page 1 of 2
Revised June 2012
1
Instructions & Resources for Use of This Form:
Use this form to request special formulas and/or medical foods for patients with qualifying medical conditions. Please refer to Georgia WIC Form
#2 (Referral Form & Medical Documentation for Special Food Substitutions) for children/women with food intolerances (e.g., lactose intolerance)
or food allergies (e.g., milk protein allergy) that can be managed with food substitutions (e.g., soy milk, tofu, etc.).
If you have questions or need additional clarification when completing this form, please contact the local WIC agency where your patient is
receiving WIC benefits. A directory of Georgia WIC clinics is available at: http://health.state.ga.us/wic_clinics/clinic_lookup.aspx. Information
about formulas and medical foods approved for issuance by the Georgia WIC Program is located at: http://wic.ga.gov/hcprovider.asp.
Local agency WIC staff will review requests for special formulas and medical foods according to federal regulations and Georgia WIC Program
policies and procedures. Diagnosis of a serious medical condition (e.g., Failure To Thrive) must be consistent with the patient’s anthropometric
data. Additional clarification or documentation may be necessary to complete the approval process. Denial of a request does not imply that WIC
Program staff question the health care provider’s clinical judgment. However, federal policy limits the issuance of special formulas and medical
foods to cases of serious diagnosed medical conditions.
Provision of special formulas and medical foods by the Georgia WIC Program will be for intervals of one (1) to six (6) months. At a minimum, a
new medical authorization is required at each renewal or formula change.
Definitions, Examples and Exclusions:
Qualifying Medical Conditions: SPECIFIC suspected or diagnosed life-threatening disorders, diseases and medical conditions that impair
the ingestion, digestion, absorption or utilization of nutrients that could adversely affect the patient’s nutritional status. Examples include, but
are not limited to:
Metabolic disorders (e.g. PKU)
Gastrointestinal disorders (e.g. Gastroesophageal Reflux Disease)
Malabsorption syndromes (e.g. Short Gut Syndrome)
Immune system disorders (e.g. Celiac Disease)
Low birth weight, premature birth, and failure to thrive (FTT)
Severe food allergies requiring use of an elemental formula (e.g. Milk Protein Allergy, Eosinophilic Esophagitis)
Non-Qualifying / Excluded Conditions:
Solely for the purpose of enhancing nutrient intake or managing body weight without an underlying condition
Non-specific formula intolerance or food intolerance
Patient preference, parental preference, or food dislikes
Medical Diagnoses:
Non-specific symptoms or diagnoses are insufficient for the purposes of Georgia WIC prescriptions (e.g., colic, milk allergy, multiple food
allergies, spitting up, milk/formula intolerance, feeding problems, feeding difficulties, picky eater, poor appetite, inadequate intake,
constipation, cramps, digestive disturbances, fussiness and gas).
The following diagnoses require an underlying medical condition be present and documented: “underweight,” “feeding disorder,”
“inadequate/poor weight gain,” and “inadequate/poor growth.” The Georgia WIC Program cannot accept these diagnoses alone – a more
specific, primary medical condition must be present and listed among the diagnoses (e.g., Cerebral Palsy, Failure To Thrive, Oral-Motor
Feeding Disorder, Prematurity, Dysphagia, etc.).
The Georgia WIC Program may require additional documentation for prescription approval if diagnoses are missing, incomplete, non-
specific, inconsistent with existing anthropometric data, or if clarification is needed.
Prescribed Formula Quantity:
Infants (<12 months of age) enrolled in the Georgia WIC Program will receive the full maximum quantity of formula allowed per month
regardless of the amount of formula prescribed per day under Section #2 of the form. The maximum quantity of formula allowed is based
on age, feeding method (Mostly Breastfed or Fully Formula Fed), product form (concentrate, ready-to-feed, powder), and product package
size. (Note: Exclusively Breastfed infants do not receive any formula from the WIC Program.)
Children and women enrolled in the Georgia WIC Program will receive the quantity of formula or medical food prescribed under Section
#2, not to exceed the maximum quantity allowed by federal regulations and Georgia WIC Program policy.
The amount of prescribed formula or medical food provided by WIC is subject to the maximum allowable quantities determined by federal
regulations and outlined in Georgia WIC Program policies. WIC is a supplemental program. Patients are responsible for acquiring any
additional prescribed quantities of formulas or medical foods that exceed what is eligible for provision by WIC.
Approximate WIC Maximum DAILY Allowances of Reconstituted Formula for Infants*
Feeding Method: Age 0 – 1 Month
Age 1 – 3 Months
Age 0 – 3 Months
Age 4 – 5 Months
Age 6 – 11 Months
Mostly Breastfed
3.5 fluid oz/day
12.0 fluid oz/day
14.5 fluid oz/day
10.5 fluid oz/day
Fully Formula Fed
27.0 fluid oz/day
29.5 fluid oz/day
21.0 fluid oz/day
*Fluid ounces based on reconstituted liquid concentrate formula. Amounts differ for ready-to-feed and reconstituted powder formulas. Refer to the federal regulations at www.fns.usda.gov/wic.
Use of Ready-To-Feed Products: Ready-to-feed products may be issued in cases where there is an unsanitary/restricted water supply, poor
refrigeration, when the patient’s caregiver has difficulty in correctly diluting concentrated or powdered formula, or when ready-to-feed is the only available
product form. In a limited number of situations, ready-to-feed products (classified by USDA as “exempt infant formulas” or “medical foods”) also may be
issued to patients with qualifying medical conditions if a ready-to-feed product (a) better accommodates the patient’s medical condition or (b) improves the
patient’s compliance in consuming the prescribed product. The patient’s local WIC clinic can provide additional guidance concerning which products
qualify for issuance in the ready-to-feed form.
We appreciate your cooperation and partnership in serving the Georgia WIC population.
In accordance with Federal Law and U .S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color,
national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW,
Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). I ndividuals who are hearing impaired or have speech disabilities may contact
USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
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Revised June 2012
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