WIC-11 dot - nj 2025

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The document outlines the medical documentation requirements for WIC (Women, Infants, and Children) services in New Jersey, specifically for the issuance of formula and approved foods for infants, children, and women. It details the responsibilities of healthcare providers in overseeing participants who require exempt infant formula or medical foods, the process for submitting requests, and the qualifying conditions that justify these needs. Additionally, it specifies which formulas do not require authorization and provides a list of WIC-eligible foods.

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Click ‘Get Form’ to open the WIC-11 dot - nj in the editor.
Begin by entering the patient’s name, current height/length, date of birth, and current weight in the designated fields.
Fill in the parent/caregiver's name and the date at the top of the form.
Specify the formula requested and amount needed. Choose between physical forms such as powder or concentrate, and indicate the intended length of use.
Detail any qualifying conditions that justify medical need. Ensure to complete Page 2 if necessary.
Indicate whether the patient can receive supplemental WIC foods by checking 'Yes' or 'No', and select applicable food items from the list provided.
Complete the health care provider section with your name, title, clinic information, and signature before submitting.

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Versions	Form popularity	Fillable & printable
2023	4.6 Satisfied (41 Votes)
2022	4.9 Satisfied (59 Votes)
2016	4 Satisfied (22 Votes)
2013	4.8 Satisfied (53 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What age does WIC stop in NJ?

To be eligible for WIC, applicants must have income at or below an income level or standard set by the state agency or be determined automatically income-eligible based on participation in certain programs.

Is WIC low income only?

Sign up for WIC today We will contact you to confirm your eligibility and complete your enrollment. In-person enrollments can be scheduled at a WIC office near you, and you will receive your food benefits the same day if you qualify.

What does WIC give you in NJ?

WIC is open to pregnant, postpartum and breastfeeding mothers and their children up to age five who meet the income guidelines and live in New Jersey.