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How to Use or Fill Out the WIC Clinic Form Online
- Click ‘Get Form’ to open it in the editor.
- Begin with Section A, 'Patient Information.' Enter the patient's name, date of birth, and the parent or caregiver's name. Include the medical diagnosis along with the appropriate ICD-9/10 code to justify the medical need for formula or food.
- In Section B, 'Medical Formula/Food,' specify the name of the requested formula or WIC Nutritionals. Indicate the prescribed amount per day or select 'maximum allowable.' Add any special instructions or comments regarding formulas tried and problems encountered.
- Proceed to Section C, 'WIC Supplemental Foods for Infants < 1 year old.' Mark any contraindicated foods and provide special instructions if necessary. If no boxes are marked, it will be assumed that all supplemental foods are acceptable.
- Finally, complete Section D by having a healthcare provider sign and print their name. Include their medical office information and contact details before submitting.
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