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How many cans of formula does wic provide in kentucky

Kentucky wic formula form 2026

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The document outlines the Kentucky WIC Program's guidelines for providing infant formula and food exceptions for non-medically fragile infants under one year old. It details the necessary forms and sections to complete for various formula requests, including standard, exempt, and medical formulas. The document also specifies the types of formulas available based on dietary needs and restrictions, along with instructions for healthcare providers to certify medical necessity.

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Click ‘Get Form’ to open the Kentucky WIC Formula Form in our editor.
Begin by filling out Section A, which requires patient information. Enter the patient's name, date of birth, and the parent or caregiver's name. Include the medical diagnosis or qualifying condition along with the corresponding ICD-9 code.
In Section B, specify the medical formula or food requested. Clearly indicate the name of the formula and prescribed amount per day. If applicable, provide any special instructions or comments regarding formulas tried and problems encountered.
Proceed to Section C to mark any contraindicated supplemental foods for infants under one year old. Ensure you check all relevant boxes based on dietary needs.
Finally, complete Section D by having a healthcare provider sign and print their name. Include their medical office details and contact information.

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