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 either Similac Advance with Early Shield or Similac Soy Isomil been completed?:

Yes

If “No,” please indicate why:__________________________________________________________________________________

Infants

 EleCare for Infants

 Neocate Infant w/ DHA & ARA

 PurAmino DHA/ARA

 Similac Sensitive 

 Enfamil EnfaCare

 Neocate Nutra (≥ 6 mo. age)

 Similac Expert Care Alimentum

 Similac for Spit-Up 

 Enfamil Nutramigen

 Pregestimil

 Similac Expert Care NeoSure

 Similac PM 60/40

 Enfamil Nutramigen w/ Enflora LGG

Children

 Boost Breeze

 Elecare Junior

 PediaSure with Fiber

 Peptamen Junior with Prebio

 Boost Kid Essentials 1.0 Cal (retail)

 Neocate Junior

 PediaSure with Fiber Enteral

 Peptamen Junior 1.5 Cal

 Boost Kid Essentials 1.5 Cal

 Neocate Jr. w/ Prebiotics

 PediaSure 1.5 Cal

 Similac Advance

 Boost Kid Essentials with Fiber 1.5 Cal

 Neocate (EO28) Splash

 PediaSure 1.5 Cal with Fiber

(≤ 12 mo corrected age)

 Bright Beginnings Soy Pediatric Drink

 Nutren Junior

 PediaSure Peptide

 Similac Soy Isomil

 Carnation Breakfast Essentials

 Nutren Junior with Fiber

 PediaSure Peptide 1.5 Cal

 Super Soluble Duocal

 Compleat Pediatric

 PediaSure

 Peptamen Junior

 Compleat Pediatric Reduced Calorie

 PediaSure Enteral

 Peptamen Junior with Fiber

Women

 Boost

 Boost Breeze

 Carnation Breakfast Essentials

 Ensure

 Super Soluble Duocal

For PKU and Metabolic Needs: WIC collaborates with the Ohio Metabolic Formula Program which supplies certain metabolic formulas prescribed 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 suplemental foods checked below:



Infant cereal

Infant fruits and vegetables

Infants (6-11 months):



Milk

Juice

Breakfast cereal

Whole grains

Fruits and vegetables

Children and Women:



Beans

Peanut butter

Eggs

Cheese

Fish (fully breastfeeding women only)



It is medically warranted for this patient to receive the following foods in addition to special formula:



Whole milk

Whole low lactose/lactose free milk

Cheese

D. Required Health Care Provider Information

Health Care Provider’s Name (please print):_______________________________________ Phone:________________________

Health Care Provider’s Signature:_______________________________________________ Date:_________________________

(Effective 10/1/14) PPL 183

ODH 3989.23

USDA is an equal opportunity provider and employer.

Ohio Wic Prescribed Formula And Food Request Form

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