WIC Formula Prescription Form 2026

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4.1 out of 5

33 votes

The document is a WIC Infant Formula Request Form that outlines the process for requesting medical formulas and nutritional products for infants and children. It requires completion of participant information, length of time requested, details about medical formulas, healthcare provider information, and justifications for specific formula needs based on medical diagnoses. The form emphasizes that all requests are subject to WIC staff approval.

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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)

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Got questions?

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

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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