Arizona wic formula 2026

1. Click ‘Get Form’ to open the Arizona WIC Special Formula Authorization Form in the editor.
2. Begin by entering the Client Name, Date of Birth, and WIC Client ID in the designated fields at the top of the form.
3. In Section 1, list any formulas previously tried. This helps healthcare providers understand past experiences with formula options.
4. For Section 2, select the current formula request from the provided options. Ensure you choose WIC rebated formulas marked with an asterisk for eligibility.
5. In Section 3, specify the amount of formula requested per day and indicate whether it will be administered orally or via tube feeding.
6. Complete Sections 4 and 5 by providing necessary medical diagnoses and checking any inappropriate foods based on dietary needs.
7. Finally, fill out Sections 6 and 7 with the length of time requested for formula authorization and print your provider's name and signature before submitting.

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