Your Guide to Benefits and Services 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the WIC ID# at the top of the form. This is essential for identification purposes.
3. Fill in the patient’s name, date of birth, current height/length, and weight. Accurate information here is crucial for proper assessment.
4. Provide details about the parent or caregiver, including their name and contact information.
5. Indicate the formula requested and any alternative formulas if necessary. Specify the amount requested and select the physical form (powder or concentrate).
6. Check any qualifying conditions that justify medical need. Ensure you complete Page 2 if additional details are required.
7. Confirm whether the patient can receive supplemental WIC foods by checking 'Yes' or 'No' and selecting applicable food items.
8. Finally, have the healthcare provider sign and date the form before submitting it via fax or email to the WIC office.

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