Fillable Ohio Wic Prescribed Formula And Food Request Form printable pdf download

Ohio WIC Prescribed Formula and Food Request Form

All requests are subject to WIC approval and provision based on program policy and procedure. Medical documentation is

federally required to issue special formulas. Please complete sections A-D of this form in full.

A. Required Patient Information

Patient’s Name:_______________________________________________________ Date of Birth: ________________________

Parent/Caregiver’s Name:_________________________________________ Weeks Born Early (if applicable): _______________

Medical Diagnosis/Condition :_________________________________________________________________________________

(Medical diagnosis must be specific and correlate to the requested formula.)

B. Required Special Formula Information

Amount of formula to be provided per DAY (must be measurable):___________________________________________________

Special Instructions/Comments:_______________________________________________________________________________



Intended length of use:

1 month

2 months

3 months

4 months

5 months

6 months (maximum)



Has a trial with Gerber Good Start Gentle, Gerber Good Start Soy, or Gerber Good Start Soothe been completed?:

Yes

If “No,” please indicate why:__________________________________________________________________________________

Infants

 Alfamino Infant 

 Pregestimil



 Similac NeoSure

 Enfamil Nutramigen

 EleCare for Infants

 PurAmino DHA/ARA

 Similac PM 60/40

 Enfamil Nutramigen w/ Enflora LGG

 Enfamil AR

 Similac Alimentum



 Neocate Infant w/ DHA & ARA

 Enfamil EnfaCare

 Similac Human Milk Fortifier

 Neocate Nutra (≥ 6 mo. age)

 Enfamil Gentlease (RTF only)

Children

 Alfamino Junior

 Compleat Pediatric Reduced Calorie 

 Nutren Junior with Fiber

 PediaSure Peptide

 Boost Breeze

 Elecare Junior

 PediaSure

 PediaSure Peptide 1.5 Cal

 Boost Kid Essentials 1.0 Cal (retail)

 EO28 Splash

 PediaSure Enteral

 Peptamen Junior



 Boost Kid Essentials 1.5 Cal

 Neocate Junior

 PediaSure with Fiber

 Peptamen Junior with Fiber

 Boost Kid Essentials with Fiber 1.5 Cal

 Neocate Jr. w/ Prebiotics

 PediaSure with Fiber Enteral

 Peptamen Junior with Prebio

 Bright Beginnings Soy Pediatric Drink

 Neocate Splash Unflavored

 PediaSure 1.5 Cal

 Peptamen Junior 1.5 Cal

 Carnation Breakfast Essentials

 Nutren Junior

 PediaSure 1.5 Cal with Fiber

 Super Soluble Duocal

 Compleat Pediatric

Women

 Boost

 Boost Breeze

 Carnation Breakfast Essentials

 Ensure

 Super Soluble Duocal

For PKU and Metabolic Needs: WIC collabor ates with the Ohio Metabolic For mula Pr ogr am which supplies cer tain metabolic for mulas pr escr ibed by an Ohio

Department of Health (ODH) approved metabolic service provider. A separate form must be completed. Please contact your WIC office for more information.

C. Required Supplemental Food Information

WIC Health Professional will issue age appropriate supplemental food unless indicated below.



No WIC supplemental foods: provide formula only.



Issue a modified food package OMITTING the supplemental foods checked below:



Infants (6-11 months):

Infant cereal

Infant fruits and vegetables



Children and Women: