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WIC Medical Documentation Form - Hawaii Department of Health 2026

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The document outlines the medical documentation requirements for the Women, Infants and Children (WIC) program in Hawaii. It includes sections for patient information, prescribed formula, WIC supplemental foods, and healthcare provider details. The document specifies qualifying medical conditions for special formulas, lists approved contract and non-contract formulas, and provides guidelines on issuing supplemental foods based on patient needs.

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Click ‘Get Form’ to open it in the editor.
Begin with Section A, where you will enter the patient’s name, date of birth, and the parent or caregiver’s name. Ensure that you also specify the medical diagnosis or qualifying condition.
In Section B, indicate the name of the prescribed formula and the daily amount required. You can choose between specifying an exact amount or selecting 'Maximum allowable'.
Proceed to Section C to select the appropriate WIC supplemental foods. Check one box based on your needs, ensuring clarity on whether to defer decisions or issue specific food packages.
Finally, complete Section D by having the healthcare provider sign and date the form. Include their printed name and contact information for verification.

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2019	4.8 Satisfied (52 Votes)
2014	3.9 Satisfied (45 Votes)

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What do you get on WIC in Hawaii?

Eat well: WIC food packages typically include cereal, juice, eggs, milk, peanut butter, dried and canned beans, tofu, fruits and vegetables, and whole-wheat bread. WIC packages also include canned fish and cheese for breastfeeding moms, and baby food for babies.

What does WIC give you in Hawaii?

WIC is a program that helps pregnant women, new parents, and young children eat well and stay healthy. Eat well: WIC food packages typically include cereal, juice, eggs, milk, peanut butter, dried and canned beans, tofu, fruits and vegetables, and whole-wheat bread.

What are the WIC food packages?

The WIC food packages provide supplemental foods designed to address the specific nutritional needs of income-eligible pregnant, breastfeeding, and non-breastfeeding postpartum individuals, infants, and children up to five years of age who are at nutritional risk.

What does the Hawaii Department of health do?

Health department employees work tirelessly to promote healthy lifestyles and workplaces, prevent disease and injury, encourage the strength and integrity of families and communities, assure basic physical and mental health care, and prevent pollution to preserve a clean, healthy and natural environment.

What is the health assessment for WIC?

The health assessment includes height; weight; and hemoglobin, a simple blood test to determine iron levels. The dietitian will also ask questions about your general health and activity levels. The nutrition assessment consists of core questions about your eating habits.

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What does WIC give moms?

Mom receives food valued at approximately $41 per month. Only mothers who choose the Fully or Mostly Breastfeeding Packages will receive WIC foods for one full year. Moms who breastfeed some or fully formula feed will receive a food package until the baby is 6 months old.

What is free with WIC?

WIC provides free, healthy foods and personalized nutrition education, breastfeeding support, referrals to other services and more. WIC now uses Electronic Benefit Transfer (EBT) cards! The WIC EBT card works just like a debit card. You can also save time with virtual appointments in many locations.

What is WIC on health form?

WIC is the Special Supplemental Nutrition Program for Women, Infants, and Children. WIC provides free healthy foods, breastfeeding support, nutrition education and referrals to other services, to support you and your family.