Georgia wic icd10 codes 2026

1. Click ‘Get Form’ to open the Georgia WIC Program Medical Documentation Form in the editor.
2. Begin by entering the patient’s first and last name along with their date of birth in the designated fields.
3. In Section 1, list the diagnosed medical condition(s) and corresponding ICD-9 or ICD-10 codes that justify the formula or medical food prescription.
4. Proceed to Section 2 to specify the special formula requested. Fill in the name of the formula, prescribed amount per day, and select the form type (Powder, Concentrate, Ready-to-feed).
5. In Section 3, choose either A or B regarding supplemental food restrictions. If there are no restrictions, initial accordingly; otherwise, check contraindicated foods and provide comments.
6. Complete Section 4 by filling out all provider information including name, title, signature, and contact details. Ensure an original signature is provided.

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