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WIC Formula and Medical Nutrition Prescription 2026
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How to Use or Fill Out the WIC Formula and Medical Nutritional Prescriptions Form Online
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient’s last name and first name in the designated fields. Ensure accuracy for proper identification.
- Fill in the parent or caregiver's last name and first name, along with the birthdate of the patient in mm/dd/yyyy format.
- In the 'Formula Prescription' section, select the appropriate formula from the list provided. Make sure to choose based on medical necessity.
- Proceed to 'Food Prescription' and indicate whether formula only or formula with foods is required, based on age and dietary needs.
- Complete the 'Diagnosis, Amount, Duration' section by specifying medical conditions justifying formula use and prescribing details.
- Finally, have a healthcare provider sign and date the form in the designated area before submission.
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Related links
Key points (noted on page 5 of the update): you must submit both F-11054 and F-11018, a copy of the original prescription or order for the formula, and.Read more
Formula/Medical Food Prescribed (Check below or specify name if not listed):. Premature: Enfamil NeuroPro EnfaCare. Similac NeoSure. Nutritional. DrinksRead more