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Your Guide to Benefits and Services 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the WIC ID# at the top of the form. This is essential for identification purposes.
- Fill in the patient’s name, date of birth, current height/length, and weight. Accurate information here is crucial for proper assessment.
- Provide details about the parent or caregiver, including their name and contact information.
- Indicate the formula requested and any alternative formulas if necessary. Specify the amount requested and select the physical form (powder or concentrate).
- Check any qualifying conditions that justify medical need. Ensure you complete Page 2 if additional details are required.
- Confirm whether the patient can receive supplemental WIC foods by checking 'Yes' or 'No' and selecting applicable food items.
- 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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