Alaska Wic Nutrition Program Enteral Nutrition Prescription Request Form - Department Of Health & Social Services - 2016

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Alaska WIC Nutrition Program Enteral Nutrition Prescription Request Form- effective March 1, 2016
State of Alaska Department of Health & Social Services/Public Assistance
Please Fax to _________________
Prescription must be completed by Health Care Provider (must be eligible to write prescriptions in AK)
Client Name ____________________________________________________________ DOB ________________________
Parent’s/Caregivers Name_________________________________ Address:________________________________Phone________
Medicaid Eligible? □ No □ Yes Medicaid # ____________________________ End date _________________________________
Current Measurements (if available): Medical date ______________ Ht =________________ in/cm Wt= ______________ lbs/kg
Formulas Requiring Medical Documentation
Similac Sensitive (19 cal/oz)
Similac for Spit Up (19 cal/oz)
Similac Total Comfort (19 cal/oz)
For these formulas, only this box needs to be completed: Reason for prescribing formula:
Malabsorption
Formula intolerance
Inappropriate Growth
Other____________________
Length of time the formula is requested for:___________________________________________________
Health Care Provider Name:_________________________Signature:______________________________
Provider Phone Number: __________________________________________________________________
For Therapeutic Formulas and Medical Foods (Listed on the back of this form) complete the information below:
Infant
Child/ Woman
____________________________________
___________________________________
F
ORMULA
F
ORMULA
Prescribed amount of formula:
Prescribed amount of formula:
_____
Maximum allowable
OR
OUNCES
______
Maximum allowable
OR
OUNCES
Milk in addition to formula
(RD can calculate, based on current weight)
S
Whole
2%
1% or skim
PECIFY
Was another Formula Tried
Yes
No
Food Prescription (check one)
Formula Tried_______________________________________
Allow age appropriate WIC foods.
Exceptions specify:
_____________________________________________
Infants 6-11 months
Check foods to avoid:
No solid foods: medical formula only
Infant Cereal
Infant cereal
Infant Fruits/Vegetables
Infant fruits and vegetables
Provide no infant foods, and increase formula amount
Allow WIC Registered Dietitian to
prescribe supplemental WIC foods
D
: 12
__________
D
: 12
__________
URATION
MONTHS OR
MONTHS
URATION
MONTHS OR
MONTHS
Please fill in Medical Diagnosis and ICD-10 Code
Both must be completed in order to process the request for
therapeutic formulas (some conditions may not qualify for special formula through WIC).
MedicalDiagnosis:___________________________________________________________
ICD-10 Code:_______________________________________________________________
Signature:________________________ Date:______________ Medical Provider Address & Phone
Medical Provider Name_____________________
Provider Medicaid ID #_____________________
WIC R
D
L
N
& M
U
O
EGISTERED
IETITIAN OR
ICENSED
UTRITIONIST
EDICAID
SE
NLY
Formula average daily calorie needs for __________ months = _________________________________________
Date __________________ RD approved __________________________ Denied_________ Date Range approved: __________
Pharmacy use only
Product _______________________________
Size ____________
Cans/day ______________ Date _____________
Pharmacist signature ________________________
XEROX use only □ Authorized □ Denied

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