Fillable Georgia WIC Program Medical Documentation Form for WIC (Georgia North Central Health District)

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Georgia WIC Program Medical Documentation Form for WIC (Georgia North Central Health District)

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*Note: The Georgia WIC Program only accepts
prescriptions authorized and signed by the
following providers:
Physicians (MD, DO)
Physician Assistants (PA, PA-C)
Nurse Practitioners (e.g., NP, APRN, CPNP,
CNP, PNP, CNNP)
Georgia WIC Program
Medical Documentation Form for WIC Special Formulas and WIC Foods
Patient’s First & Last Name: ________________________________________ Date of Birth (MM/DD/YY): _____________
Parent/Caregiver’s First & Last Name: ___________________________________________________________________
List the SPECIFIC diagnosed or suspected medical condition(s) and the ICD-9 or ICD-10 code(s) justifying the formula/medical
food prescription.
Qualifying diagnosed medical condition(s): __________________________________________________________________
And applicable ICD-9 or ICD-10 code(s): ___________________________________________________________________
Note: WIC approval and provision of prescription formulas and medical foods are based on Georgia WIC Program policies and procedures.
Name of formula/medical food requested: ___________________________________________________________________
Prescribed ounces per day: _______________ oz/day* Form: Powder Concentrate Ready-to-feed
†
Special instructions/comments**: __________________________________________________________________________
If Applicable: Flavor: ____________________________________ With Fiber: Yes No N/A
Planned length of use: ___________ months WIC prescription renewal is required periodically (every 1-6 months).
*
Prescribed amount per day is based on reconstituted fluid ounces of the formula product at standard dilution. Instructions on reverse.
**Prematurity: With documentation, premature infants can receive infant formula past one year to account for adjusted age. Medical
documentation will need to be provided at the one year WIC certification.
†
The use of ready-to-feed products requires additional justification for WIC unless ready-to-feed is the only available product form.
Check the box to indicate all WIC foods are allowed or indicate any contraindicated supplemental foods below.
No Supplemental Food Restrictions. (All WIC foods allowed.)
Contraindicated Supplemental Foods – Check the foods that should NOT be issued to the patient.
Infants
(6-11 mos.)
Infant Cereal
Baby Food Fruits and Vegetables
Children
(≥ 12 mos.)
& Women
Milk
Beans / Peas
Vegetables / Fruits
Whole Grains (wheat bread,
brown rice, or whole grain
tortillas)
Cheese
Peanut Butter
Juice
Cereal
Eggs
Canned Fish*
Comments:
Please describe any other prescribed restrictions or special requests in the “Comments” section below. (Developmental readiness, allergies, tube fed, NPO, etc.)
* Only for exclusively breastfeeding women, women pregnant with multiple fetuses, pregnant women breastfeeding, and women mostly breastfeeding multiple infants.
Original signature required. No stamped signatures or proxy signatures (e.g., by nursing staff) will be accepted.
Medical Office/Clinic Name:
Street Address:
City:
Zip Code:
Phone Number:
Fax Number:
3. WIC Foods
1. Qualifying Medical Condition(s)
4. Health Care Provider Information (Please Complete All Boxes.)
2. Special Formula Requested
Date:
Provider’s Signature/*Title:
Provider’s Name (Please Print):
1
Page 1 of 2
Revised September 2016
Use this form to request special formulas and/or medical foods for patients with qualifying medical conditions.
If you have questions or need additional clarification when completing this form, please contact the local WIC agency where your patient is
receiving WIC benefits. A directory of Georgia WIC clinics is available at: www.WIC.GA.GOV
(Select “Clinic Listing”) Information about
formulas and medical foods approved for issuance by the Georgia WIC Program is located under the “Health Care Provider” tab. .
Local agency WIC staff will review requests for special formulas and medical foods according to federal regulations and Georgia WIC Program
policies and procedures. Diagnosis of a serious medical condition (e.g., Failure To Thrive) must be consistent with the patient’s anthropometric
data. Additional clarification or documentation may be necessary to complete the approval process. Denial of a request does not imply that WIC
Program staff question the health care provider’s clinical judgment. However, federal policy limits the issuance of special formulas and medical
foods to cases of serious diagnosed medical conditions.
Provision of special formulas and medical foods by the Georgia WIC Program will be for intervals of one (1) to six (6) months. At a minimum, a
new medical authorization is required at each renewal or formula change.
Qualifying Medical Conditions: SPECIFIC suspected or diagnosed life-threatening disorders, diseases and medical conditions that impair
the ingestion, digestion, absorption or utilization of nutrients that could adversely affect the patient’s nutritional status. Examples include, but
are not limited to:
Metabolic disorders (e.g. PKU)
Gastrointestinal disorders (e.g. Gastroesophageal Reflux Disease)
Malabsorption syndromes (e.g. Short Gut Syndrome)
Immune system disorders (e.g. Celiac Disease)
Low birth weight, premature birth, and failure to thrive (FTT)
Severe food allergies requiring use of an elemental formula (e.g. Milk Protein Allergy, Eosinophilic Esophagitis)
Non-Qualifying / Excluded Conditions:
Solely for the purpose of enhancing nutrient intake or managing body weight without an underlying condition
Non-specific formula intolerance or food intolerance
Patient preference, parental preference, or food dislikes
Medical Diagnoses:
Non-specific symptoms or diagnoses are insufficient for the purposes of Georgia WIC prescriptions (e.g., colic, milk allergy, multiple food
allergies, spitting up, milk/formula intolerance, feeding problems, feeding difficulties, picky eater, poor appetite, inadequate intake,
constipation, cramps, digestive disturbances, fussiness and gas).
The following diagnoses require an underlying medical condition be present and documented: “underweight,” “feeding disorder,”
“inadequate/poor weight gain,” and “inadequate/poor growth.” The Georgia WIC Program cannot accept these diagnoses alone – a more
specific, primary medical condition must be present and listed among the diagnoses (e.g., Cerebral Palsy, Failure To Thrive, Oral-Motor
Feeding Disorder, Prematurity, Dysphagia, etc.).
The Georgia WIC Program may require additional documentation for prescription approval if diagnoses are missing, incomplete, non-
specific, inconsistent with existing anthropometric data, or if clarification is needed.
Prescribed Formula Quantity:
Infants (<12 months of age) enrolled in the Georgia WIC Program will receive the full maximum quantity of formula allowed per month
regardless of the amount of formula prescribed per day under Section #2 of the form. The maximum quantity of formula allowed is based
on age, amount of breastmilk (Mostly Breastfed or Fully Formula Fed), product form (concentrate, ready-to-feed, powder), and product
package size. (Note: Exclusively Breastfed infants do not receive any formula from the WIC Program.)
Children and women enrolled in the Georgia WIC Program will receive the quantity of formula or medical food prescribed under Section
#2, not to exceed the maximum quantity allowed by federal regulations and Georgia WIC Program policy.
The amount of prescribed formula or medical food provided by WIC is subject to the maximum allowable quantities determined by federal
regulations and outlined in Georgia WIC Program policies. WIC is a supplemental program. Patients are responsible for acquiring any
additional prescribed quantities of formulas or medical foods that exceed what is eligible for provision by WIC.
Approximate WIC Maximum DAILY Allowances of Reconstituted Formula for Infants*
Feeding Method:
Age 0 – 1 Month
Age 1 – 3 Months
Age 0 – 3 Months
Age 4 – 5 Months
Age 6 – 11 Months
Mostly Breastfed
3.5 fluid oz/day
12.0 fluid oz/day
14.5 fluid oz/day
10.5 fluid oz/day
Fully Formula Fed
27.0 fluid oz/day
29.5 fluid oz/day
21.0 fluid oz/day
*Fluid ounces based on reconstituted liquid concentrate formula. Amounts differ for ready-to-feed and reconstituted powder formulas. Refer to the federal regulations at www.fns.usda.gov/wic.
We appreciate your cooperation and partnership in serving the Georgia WIC population.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees,
and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or
retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.),
should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through
the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested
in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Instructions & Resources for Use of This Form:
Definitions, Examples and Exclusions:
1
Revised September 2016
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Georgia WIC Program Medical Documentation Form for WIC (Georgia North Central Health District)

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Completed 21 April 2021

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