Ohio Wic Prescribed Formula And Food Request Form Page 2
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2Instructions for use of this form:
All special formula requests are subject to WIC approval and provision based on program policy and procedure.
Medical documentation is federally required to issue special formulas.
Section A
Section A must be completed in full for all patients. Medical diagnoses or conditions must be specific, and correlate
with the indications for use of the requested formula. Special formulas cannot be provided by WIC solely for the
purpose of enhancing nutrient intake or managing body weight. Pediatric beverages cannot be issued solely for the
following: a child refuses to take a multivitamin; a child is a picky eater; a child is underweight, but is not diagnosed as
having failure to thrive, and the diet can be managed using regular foods; a child is assessed to be at risk for or is
overweight; or, a child is assessed to be at an average Body Mass Index.
Section B
Section B must be completed for all patients.
The amount of formula provided per day must be measurable. Quantities such as “maximum,” “prn,” or “as
needed” will not be accepted.
The space for special instructions or comments can be used as needed. An open line of communication to the local
WIC office is encouraged by including more information in this area, which may lead to more timely approval of
the special formula requested. Please note that if RTF is requested, this form of formula will require additional
justification and will need to meet WIC standards.
An intended length of use must be indicated. Six (6) months is the maximum length of time WIC can provide a
special formula without a new Ohio WIC Prescribed Formula and Food Request Form.
Only one formula can be selected on this form. WIC cannot provide more than one formula in a month.
Section C
If Section C is not completed, the WIC Health Professional will issue a food package as appropriate based on objective
interview and patient preference. However, if whole milk, whole low lactose/lactose free milk, or cheese are to be
provided, the health care provider must indicate that in the bottom part of Section C.
Section D
Section D must be completed in full for all patients. Only a physician, nurse practitioner, or physician’s assistant may
sign off on this form. No other health care providers are authorized to sign. Health care providers must clearly print
their name in addition to their signature or stamp. The date the form was signed must be provided.
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