Fillable State of Hawaii - WIC Program Medical Documentation Form

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State of Hawaii - WIC Program Medical Documentation Form

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WIC Form FD 941C August 2016 This institution is an equal opportunity provider. Page 1 of 2
State of Hawaii, Department of Health
Women, Infants and Children (WIC) Program
Medical Documentation Form
Complete sections A, B, C and D for all patients.
Form available at: http://health.hawaii.gov/wic
WIC Clinic:
Phone #:
Fax #:
Contact Name:
A. Patient Information
Patient’s name (Last, First, MI):
DOB:
Parent/Caregiver’s name (Last, First, MI):
Medical diagnosis/qualifying condition: _________________________________________________________________________________
(Note: Colic, constipation, spitting up, and formula intolerance are not qualifying conditions for special formula.)
Medical documentation valid for: 1 month 2 months 3 months 4 months 5 months 6 months
B. Formula
Name of formula:
Prescribed amount: ____________________ oz per day or Maximum allowable
C. WIC Supplemental Foods
Supplemental foods: (Check one box below. If no box is selected, decision will be deferred to WIC Registered Dietitian or Nutritionist)
Defer decision to WIC Registered Dietitian or Nutritionist
All: Issue all age-appropriate WIC supplemental foods listed below
None: No WIC supplemental foods for Infants (6-11 months)/Children/Women; provide formula only
Modified: Issue a modified food package REMOVING the supplemental foods checked below.
WIC Supplemental Foods to REMOVE
Special Instructions
No infant cereal
No infant fruits and vegetables
No milk
No peanut butter
No eggs
No beans
No cheese
No breakfast cereals
No juice
No whole grains
No fresh fruits and vegetables
No canned fish (Exclusive
breastfeeding women only)
Milk Options for Children (1 - 4 years) and Women:
Nonfat Milk Lowfat (1%) Milk Reduced-fat (2%) Milk Whole Milk*
(WIC will provide whole milk for children 12 to 23 months of age and lowfat (1%) and nonfat milk for children > 2 years and women if no
option is selected. *Whole milk may be given to children > 2 years and women only with a prescribed formula)
D. Health Care Provider Information
Signature of health care provider: Date:
Provider’s name (please print): MD DO NP PA
Medical office/clinic:
Phone #: Fax #: Email:
WIC USE ONLY
Approved by:
Date:
WIC ID:
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WIC Form FD 941C August 2016 This institution is an equal opportunity provider. Page 2 of 2
HAWAII WIC APPROVED CONTRACT AND NON-CONTRACT FORMULA
WIC participants with a qualifying medical condition are eligible to receive non-contract formulas listed below.
Formula(s)
Diagnosis/condition
(Medical reason for request)
Similac Advance
Contract – Milk-based formula (20 kcal/fluid oz.)
Similac Sensitive
Contract – Milk-based, lactose-free formula (Requires Med Doc form due to 19 kcal/fluid oz.)
Good Start Soy
Contract – Lactose-free, sucrose-free, soy-based formula (20 kcal/fluid oz.)
Beneprotein
For increased protein needs. Nutritionally incomplete.
Enfaport
Nutritionally complete formula for infants with Chylothorax or LCHAD deficiency.
Contains 84% of its fat from MCT oil. (30 kcal/fluid oz.)
EnfaCare /
Similac Neosure
Prematurity and/or low-birth weight infants. (22 kcal/fluid oz.)
Free Amino Acid Elemental Formulas:
EleCare for Infants / EleCare Jr /
Neocate / Neocate Jr / PurAmino
For infant or child with severe malabsorption, protein maldigestion, severe food allergies,
short bowel syndrome, and/or GI impairment.
Metabolic formulas: Cyclinex / I-Valex
Glutarex / Hominex / Ketonex / Phenex
Metabolic disorders. (WIC does not provide medical nutritional therapy for metabolic
disorders)
Nutramigen Enflora LGG /
Similac Alimentum
Hypoallergenic formula for infants with an allergy or sensitivity to intact proteins in cow’s
milk and soy formulas, as well as other foods.
Pediatric Formulas: Child > 1 yr.
Nutren Jr. with or without fiber /
Pediasure with or without fiber
For children with chronic illness, oral motor feeding problems, tube feeding or medical
conditions which increase caloric needs beyond what is expected for age. WIC will not
provide for sole purpose of enhancing nutrient intake or managing body weight.
Note: Medicaid will provide formula for Medicaid blind and/or disabled infants &
children that are tube fed. Not for children with Galactosemia.
Peptamen Junior
Children with GI impairment, e.g. Inflammatory Bowel, Cystic Fibrosis or Short Bowel
Syndrome.
Portagen
Pancreatic insufficiency, bile acid deficiency or lymphatic anomalies. Not for infants.
Nutritionally incomplete.
Pregestimil
Fat malabsorption and sensitivity to intact proteins. Contains 55% of fat from MCT oil.
ProViMin
Malabsorption of carbohydrate and/or fat; supplement for patient who requires increased
protein, minerals, and vitamins.
Ross Carbohydrate Free
Inability to tolerate type or amount of carbohydrate in milk or conventional formula; or need
for ketogenic diet.
Similac Human Milk Fortifier (HMF)
Added to breastmilk for low birth weight and premature infants. HMF can be issued
until the infant reaches a maximum weight of 8 lbs.
Similac PM 60/40
Renal or cardiac conditions requiring low mineral level.
Similac for Spit-Up
Treatment of medically diagnosed Gastroesophageal Reflux Disease.
Similac Special Care Advance 24
Premature and low-birth weight infants. Not intended for feeding low birth weight infants
after they reach a weight of 8 lbs.
Similac Total Comfort
Inability to tolerate whole cow-milk protein. (Partially hydrolyzed protein, milk-based
formula - 19 kcal/fluid oz.)
Vivonex Pediatric
Children with severe GI impairment, e.g. Crohn’s disease, Short Bowel Syndrome, intestinal
failure, GI trauma/surgery, or Malabsorption syndrome.
Hawaii WIC is unable to provide the following formulas, even with medical documentation
No Similac soy infant formula: Similac Soy Isomil
No Similac or Enfamil Supplementation formula: Similac for Supplementation or Enfamil for Supplementing
No Gerber standard milk-based formula: Good Start Gentle or Good Start Soothe
No Enfamil standard infant formulas: Enfamil PREMIUM, Enfamil ProSobee, Enfamil AR, or Enfamil Gentlease
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State of Hawaii - WIC Program Medical Documentation Form

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Completed 24 May 2020

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