Georgia wic 2026

1. Click ‘Get Form’ to open the Georgia WIC Medical Documentation Form in the editor.
2. Begin by entering the patient’s first and last name along with their date of birth in the designated fields.
3. In Section 1, list any qualifying medical conditions along with their corresponding ICD-9 or ICD-10 codes. This information is crucial for justifying the special formula request.
4. Proceed to Section 2 to specify the special formula requested. Fill in the name of the formula, prescribed ounces per day, and select the form type (Powder, Concentrate, or Ready-to-feed).
5. Complete Section 3 by indicating if there are any supplemental food restrictions. If none, initial the appropriate line; otherwise, check contraindicated foods as necessary.
6. Finally, fill out Section 4 with healthcare provider information including signature and credentials. Ensure all boxes are completed accurately.

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