Form Wc-51 - Special Formula Request Form - Arkansas Department Of Health printable pdf download

ARKANSAS DEPARTMENT OF HEALTH

WIC PROGRAM

SPECIAL FORMULA REQUEST

WIC may provide the following formulas with documented medical reason/diagnosis. Supplemental foods will only be issued with

approval of a physician, physician assistant with prescriptive authority or advanced practice registered nurse with prescriptive

authority. All prescriptions are reviewed by a WIC Registered Dietitian.

Name of Infant/Child____________________________________________

Date of Birth___________________________

Height/Length______________________ Weight________________________

Date Taken____________________________

Note: Ready-to-Use formula can be issued if the caretaker is physically or mentally unable to prepare formula or if water supply is unsafe.

TO REQUEST A SPECIAL FORMULA:

5. Indicate the amount needed per day.

1. Review the descriptions for use.

2. Check selected formula listed below or on back.

6. Select supplemental foods to be restricted.

3. Write in diagnosis.

7. Complete date and sign* on back.

4. Circle number of months prescribed.

*signature must be from MD, PA, APRN, or DO with prescriptive authority

Note: Special exempt formula may only be provided for a maximum period of three months. Exceptions which may warrant longer approval

period up to six months are: tube feeding, PKU, galactosemia, cystic fibrosis, short bowel syndrome, fatty acid oxidation disorders (FAOD),

diagnosed cow’s milk allergy (CMA), specified malabsorption, preterm infants discharged on a preterm transitional formula, palliative care,

conditions requiring the use of Similac PM 60/40.

Formula

Descriptions for Use

Diagnosis

Duration & Amount

Allergy to milk and/or soy protein; severe

1, 2, 3, 4, 5, 6 month(s)

Alimentum—Abbott

malnutrition; chronic diarrhea, short bowel

syndrome; known or suspected corn allergy

_________oz/day

Allergy to intact protein and casein hydrolysates;

1, 2, 3, 4, 5, 6 month(s)

Neocate Infant DHA &

severe food allergies; short bowel syndrome;

ARA*—Nutricia

malabsorption

_________oz/day

Neocate Jr. with

Prebiotics*—Nutricia

Neocate Jr. is intended for children over the age

Unflavored

of one; standard dilution is 30 calories per ounce

Vanilla

Preterm infant transitional formula for use

1, 2, 3, 4, 5, 6 month(s)

Enfacare—Mead

between premature formula and term formula;

Johnson

must have minimum weight of 1800 grams

_________oz/day

or 4 pounds. Not approved for an infant

previously on term formula or a term infant for

increased calories.

Milk or soy allergy; other food allergies; sensitivity

1, 2, 3, 4, 5, 6 month(s)

Nutramigen Enflora

to intact protein; chronic diarrhea; GI bleeds

LGG*—Mead Johnson

_________oz/day

Nutramigen DHA &

Note: Powdered Nutramigen Enflora LGG may

ARA—Mead Johnson

be used for galactosemia

(RTU or concentrate only)

Pancreatic insufficiency, bile acid deficiency or

1, 2, 3, 4, 5, 6 month(s)

Portagen*—Mead

lymphatic anomalies; biliary atresia; liver disease;

Johnson

chylothorax

_________oz/day

Fat malabsorption and sensitivity to intact

1, 2, 3, 4, 5, 6 month(s)

Pregestimil—Mead

proteins; cystic fibrosis; short bowel syndrome;

Johnson

intractable diarrhea; severe protein calorie

_________oz/day

malabsorption

PKU; Hyperphenylalaninemia

1, 2, 3, 4, 5, 6 month(s)

PKU Periflex Early Years*

—Nutricia

_________oz/day

Periflex Infant for infants

PKU Periflex Junior Plus*

—Nutricia

Periflex Junior for toddlers and children

Renal, cardiac or other condition that requires

1, 2, 3, 4, 5, 6 month(s)

Similac PM 60/40*

lowered minerals

—Abbott

_________oz/day

Preterm, low birthweight infants; not intended for

1, 2, 3 month(s)

Gerber Good Start

use after a weight of 8 pounds is reached. Not

Premature 24—Gerber

approved for an infant previously on term formula

_________oz/day

or a term infant for increased calories

* Indicates formula is available in powder only

WIC-51 (R 3/16)

Form Wc-51 - Special Formula Request Form - Arkansas Department Of Health

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