CDPH 247 at a glance
What it is: CDPH 247 is the Medical Formula and Nutritionals Request Form of the California Department of Public Health WIC Program.
Who signs: Sign the Provider Signature line.
If the patient is covered by Medi-Cal, request PA at https://medi-calrx.dhcs.ca.gov/provider/forms. WIC only provides medically necessary formula/nutritionals when patients are not covered by Medi-Cal.
A filled-in CDPH 247 example: a provider requests Similac Alimentum for an infant
How to fill out CDPH 247, box by box
Section I: Participant/Patient and Health Care Information
In Section I, enter the WIC Agency, the WIC ID#, the Patient Name (First, Last), the Date of Birth, the Parent/Caregiver Name (First, Last) and the Phone Number.
Enter Height/Length (inches) and Weight (lb, oz) as Current with its Date (Within 60 days) and as At birth.
Enter Hemoglobin (gm/dL) or Hematocrit (%), Lead Test (mcg/dL) and the Lab Result Date.
Under Breastfeeding (birth to 12 months), check Fully breastfeeding, Never breastfed, Feeding breastmilk & formula, or Discontinued breastfeeding on and enter that date.
Patient's Health Insurance
Medi-Cal: the Health Care Provider (HCP) must submit a Prior Authorization (PA) to Medi-Cal, and the patient takes the Rx to a Medi-Cal pharmacy.
Private (does not cover enteral products).
Section II: Medical Formula/Nutritionals and Qualifying Diagnosis
Under Formula/Medical Food Prescribed, check a formula in Section II or specify the name if not listed.
Form (Check one): Powder, Concentrate or Ready-to-Feed (RTF); the Justification for RTF is required unless RTF is the only available form.
Duration (Check one): 1 month, 2 months, 3 months, 4 months, 5 months or 6 months; enter the Amount in fluid ounces / ounces per day.
Qualifying Diagnosis (Must specify): Prematurity (Adjusted age: months), Low birthweight, Failure to thrive, Dysphagia, Food allergy, Immune system disorder, Gastrointestinal disorder, Life-threatening disorder, Malabsorption (Nutrient), Genetic/Metabolic disorder or Other medical condition(s).
Section III: WIC Food Restrictions
In Section III: WIC Food Restrictions (Check one), check No food restrictions (all WIC foods allowed) or Food restrictions (specified in Section III).
Under Infants (6-11 Months): No infant cereal, No infant fruits/vegetables, No infant foods, increased formula, No fruits/vegetables (fresh, frozen, canned), and If premature: Provide infant foods after months.
Under Children (1-5 Years): No milk, No cheese, No eggs, No yogurt, No plant-based milk alternatives, No tofu, No juice, No peanut butter, No beans, No cereal, No fruits/vegetables, No whole grains (Specify type(s)), No canned fish (light tuna, salmon, sardines), Needs purees; provide infant fruits/vegetables, and No foods (formula only).
Enter Comments.
Section IV: Health Care Provider Information
In Section IV: Health Care Provider Information, check MD, DO, NP or PA, print the Provider Name, and enter the Medical Office/Clinic Name and Address, the Provider Signature, the Date and the Phone Number.
More rules for CDPH 247
For more information on WIC formulas: Scan the QR code (right), visit www.wicworks.ca.gov, and click on Health Care Providers, or call 1-800-852-5770.
Common questions about CDPH 247
Who signs it?
Sign the Provider Signature line.
When is this form not the right one?
WIC will not approve medical formula or medical food for non-specific symptoms or diagnoses (e.g., colic, constipation, diarrhea, spitting up, picky eater, poor appetite, cramps, fussiness, gas, etc.), solely to enhance nutrient intake or manage body weight without an underlying condition, non-specific formula intolerance or food intolerance, or patient/caregiver preference or food dislikes.
Sources
[1] CDPH 247 (English) Rev 04/26, Medical Formula and Nutritionals Request Form, California Department of Public Health (the Official source link on this page).