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WIC Formula Prescription Form 2026
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- Click ‘Get Form’ to open the WIC Formula Prescription Form in our editor.
- Begin with Section A, Participant Information. Fill in your name, date of birth (DOB), and today’s date accurately.
- Move to Section B, Length of Time Requested. Circle the appropriate option or fill in a specific end date for formula needs.
- In Section C, Medical Formulas/Nutritional Products, specify the prescribed amount and select the relevant infant formula options based on medical necessity.
- Provide justification for any other formulas requested and check the appropriate diagnosis boxes that apply to your situation.
- Complete Section D by entering your healthcare provider's information, including their printed name, signature, and phone number.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2021 | 4.1 Satisfied (33 Votes) |
Can you get free formula from WIC?
WIC will usually cover specialty formulas as long as they are under the brand umbrella for whatever brand the state contracts with. If your state covers Similac and Enfamil, they should cover Alimentum or Nutramigen with a prescription from the doc.
Can you get a prescription for baby formula?
Most CVS stores allow WIC recipients to use their pre-paid card to purchase nutritional items. In 2022 CVS accepts EBT cards for payment at over 6,900 stores, but there are some that do not so it is recommended that you check with your local CVS before visiting.
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wic special formula form
WHEN PRESCRIBING A FORMULA IN READY-TO-USE (RTU) FORM, COMPLETE SECTION B AND CHECK THE APPROPRIATE REASON BELOW. Accommodates the participants condition
The Medical Documentation Health Care Provider Authorization Form (WIC-27) is required to prescribe non-contract standard infant formula, exempt infant
I chose a formula labeled as useful for a problem my baby had .. □. I chose the same formula fed to my baby at the hospital. □. I use the formula given by