WIC Formula and Medical Nutrition Prescription 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s last name and first name in the designated fields. Ensure accuracy for proper identification.
3. Fill in the parent or caregiver's last name and first name, along with the birthdate of the patient in mm/dd/yyyy format.
4. In the 'Formula Prescription' section, select the appropriate formula from the list provided. Make sure to choose based on medical necessity.
5. Proceed to 'Food Prescription' and indicate whether formula only or formula with foods is required, based on age and dietary needs.
6. Complete the 'Diagnosis, Amount, Duration' section by specifying medical conditions justifying formula use and prescribing details.
7. Finally, have a healthcare provider sign and date the form in the designated area before submission.

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