Medical Documentation Form w - PHPA - Maryland 2025

1. Click ‘Get Form’ to open the Medical Documentation Form w - PHPA - Maryland in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. In the 'Exempt Infant Formula/WIC-Eligible Nutritional Request' section, provide a clear medical diagnosis that justifies the request. This is a required field.
4. Select the WIC product requested from the options available, ensuring it aligns with the medical diagnosis provided.
5. Indicate the amount prescribed per day and select the requested duration for which this formula is needed. Remember, reauthorization may be necessary for durations beyond six months.
6. Complete the WIC Food Restrictions/Requests section by checking all applicable boxes. This helps determine appropriate supplemental foods.
7. Finally, fill in your provider's name, phone number, and signature along with today's date to validate the form before submission.

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