New Mexico Wic Prescription Form PDF Details

In the heart of New Mexico's efforts to support the nutritional needs of infants, children, and women under the Women, Infants & Children (WIC) program, lies the New Mexico WIC Medical Request for Formula/Food form. This document facilitates the provision of essential formula and food to those who have specific medical needs or conditions that regular WIC offerings cannot meet, ensuring that every beneficiary receives tailored nutritional support. The form requires detailed patient information, including the name, date of birth, and medical diagnosis coded per the International Classification of Diseases (ICD-9), which underscores the medical necessity for special formulas or foods. Notably, the form lists a broad spectrum of conditions, such as allergies, autoimmune disorders, and various other health issues that can affect nutritional intake and growth. The healthcare provider's endorsement, essentially through their signature, mandates a careful consideration of each request, abiding by program policies and conditions that underscore the safety and well-being of the participants. Section B of the form delineates the formula or food requested, including the amount and duration of the supply, demonstrating the program's adaptability to the specific nutritional needs and medical conditions of its participants. Moreover, it highlights the federal guidelines that cap the provision to a maximum allowed by law unless a greater need is indicated, showcasing the balance between individual care and regulatory compliance. Additionally, with a nod to inclusivity and anti-discrimination, the form concludes with a statement aligning with federal law and USDA policy, ensuring equal opportunity and provision for all eligible individuals regardless of race, color, national origin, sex, age, or disability, cementing the form's role not just in nutrition but in upholding principles of equity and justice.

QuestionAnswer
Form NameNew Mexico Wic Prescription Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesPediasure, Gerber, New_Mexico, wic prescription formula nm printablw

Form Preview Example

New Mexico WIC Medical Request for Formula/Food

Directions for completing this form and other information are on reverse side.

All requests are subject to WIC approval and provision based on program policy and procedure

 

A. Required Patient Information

 

 

 

 

 

 

 

 

 

Patient’s Last Name: MYRA

 

 

First Name

JOHNSON

DOB___________

 

Parent/Caregiver’s Name:_______________________________________________________________________________

 

Qualifying Condition/Diagnosis/ICD-9code: __________________________________________________________________

 

Allergy, confirmed [Cow’s milk protein, soy] (693.1) 353 Autoimmune Disorder (279.4) 352

Cerebral Palsy (343.9) 348

 

 

 

 

Cystic Fibrosis (277.00) 360

 

Congenital Anomaly, Respiratory (748.9) 360 Congenital Heart Disease (746.9) 360

 

Developmental Sensory/Motor Delays (783.40) 362

Failure to Thrive (C-783.41, W-786.7) 134 Gastroesophageal Reflux (580.81) 342

 

Immunodeficiency (279.3) 352

 

Inadequate growth(783.40) 135

Intestinal Malabsorption (579.9) 342

 

 

 

 

Lactose or Sucrose Intolerance (271.3) 355

 

Low Birth Weight(765.10) 141

Low Maternal Wt Gain (646.83) 131

 

 

 

 

Metabolic Disorders (277.9) 351

 

Neuromuscular Disorder (358.9) 349

Prematurity (765.10) 142

 

 

 

 

Pyloric Stenosis (537) 342

 

Seizure disorder requiring ketogenic diet (345.90) 348

 

Underweight (783.22) Women- 101, Inf/C-103

 

 

 

 

 

 

 

 

 

Cancer: type: __________ ICD-9 code: ________ 347

Other medical condition: ________________________ICD-9 code: __________360

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

***NOT ALLOWED: constipation, diarrhea, unconfirmed allergies, or for managing body weight, lactose intolerance symptoms, or growth

 

 

 

 

 

concerns unless there is an underlying medical condition.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measurements:

 

 

 

 

 

 

 

 

Date: _____________ Length/Height __________Weight __________ If premature: Birth Weight ________Weeks Gestation_____

 

 

 

 

 

 

 

 

 

 

B. Name of Formula(s):____________________________________________________________________

 

 

 

 

 

Requested length of issuance:

3 months

6months

Formula amount: __________ per day*

 

 

 

 

*Maximum allowed by federal guidelines (6 months) will be provided unless otherwise indicated

 

 

 

 

Infants (6-12 months old)

Full provision of formula and infant foods will be issued unless checked below

Provide only formula past 6 months of age due to inability or delay in consuming solids

Infants unable to eat and on therapeutic (non-standard) formula may be eligible for an increased amount of formula.

Check WIC Supplemental Food to OMIT at 6 months of age

Infant Cereal

Baby Food

 

(Fruit &/or Vegetables)

Children (1-5 years old) and Women

All appropriate WIC foods, except milk, will be issued

with prescribed formula unless checked below

Provide whole milk in addition to formula

For milk allergy, formula or Goat milk___________________

Provide infant foods for cash value fruits/vegetables

No supplemental foods. Provide formula only

Check WIC Supplemental Foods to OMIT from Food Package

 

P-nut

 

 

Cheese

Butter

Cereal

Juice

 

 

Whole

Fruits/

Eggs

Beans

Grains

Veg.

C.Required Health Care Provider Information

Signature/stamp of Health Care Provider (MD, DO, PA,NP):___________________________________Date:_____________________________________________

Provider’s Name (Please Print) ____________________________________________________________________________________________________________

Phone No: _______________________________________ Fax No: _____________________________________________________________________________

Provider allows WIC Nutritionist or RD to select and advise client on appropriate foods______________________________________________________________

Federal regulations require all WIC programs to obtain a formula rebate contract for cost containment. NM WIC contracts with Nestles, Gerber formulas.

 

New Mexico Medical Request for Formula/Food

Directions:

For ALL PATIENTS: Complete Sections A

 

For MEDICAL FORMULA AND FOOD: Complete Section B

 

For HEALTH CARE PROVIDER SIGNATURE: Complete Section C

Please return this form to participant’s WIC clinic. (FAX is acceptable)

The following formulas are available from NM WIC (Women, Infants & Children)

 

Star Medical Issued Formula

Standard e-WIC Card Issued Formulas

NO RX Needed

 

 

(Infants & Children)

 

(Women, Infants & Children)

for Infants under

 

 

 

 

 

12 mo

 

 

Boost Kid Essentials 1.0 8oz (children)

Alimentum powder 16oz 22 cal/per/oz (infants/children)

 

 

 

Boost Kid Essentials 1.5 8oz (children)

Alimentum RTF 32oz (infants/children)

 

 

 

Boost Kid Essentials 1.5 w/fiber 8oz (children)

Boost Kid Essentials 8.25oz – van/choc (children)

 

 

 

 

 

 

 

 

Bright Beginnings Soy RTF 8 oz (children)

Boost Plus RTF 8oz (women and children)

 

 

 

 

 

 

 

 

Elecare DHA/ARA 14.1 oz powder (infants/child)

Enfacare powder 12.8oz 22 cal/per/oz (infants/children)

 

 

 

 

 

 

 

 

Elecare Jr. Vanilla/plain powder 14.1oz

Ensure RTF 8oz (women)

 

 

 

(children)

 

 

 

 

 

 

 

 

 

 

Enfacare RTF 32oz 22 cal/per/oz

Gerber GS Gentle powder 12.7 oz (infant/child)

X

 

 

(infants/children)

 

 

 

 

 

Enfamil Enfaport RTF 6 oz (infants)

Gerber GS Gentle Conc. 12.1 oz (infant/child)

X

 

 

Enfamil Premature 24 cal 2 oz RTF

Gerber GS Gentle RTF 8.45 oz 4pk( infant/child)

X

 

 

(infants/child)

 

 

 

 

 

Enfamil Premature Hi Pro 24 cal 2oz RTF

Gerber Good Start Gentle for supplementing 12.4 oz

X

 

 

(infants)

 

(inf/child)

 

 

 

Gerber GS Premature 24 cal RTF 3oz (infants)

Gerber Good Start Soothe powder 12.4 oz (inf/child)

X

 

 

Hominex 1 powder 14.1oz (infants/children)

Gerber Good Start Soy powder 12.9 oz (infant/child)

X

 

 

Hominex 2 powder 14.1 oz(Children)

Gerber Good Start Soy Concentrate 12.1 oz (infant/child)

X

 

 

Ketocal 4:1 RTF (children)

Gerber Good Start Soy RTF 8.45 oz 4 pk (infant/child)

X

 

 

Monogen powder 14.3oz (infants)

Neosure Expert Care pwd 13.1 oz 22 cal (infant/child)

 

 

 

Neocate DHA/ARA powder 14.1oz (infant/child)

Nutramigen Enflora pwd 12.6 oz

 

 

 

Neocate Jr powder 14oz (trop frt,choc,strawbry)

Pediasure RTF 8 oz multiple flavors 6 pk(child)

 

 

 

Neocate Jr. w/prebiotics 14oz Plain/Van (child)

Pediasure w/fiber RTF 8 oz vanilla(child)

 

 

 

Neosure RTF 32 oz 22 cal/per/oz (infants)

Gerber Graduates Gentle Toddler pwd 22 oz (children)

 

 

 

Nutramigen con. 13 oz (infants/children)

Gerber Graduates Protect pwd 22 oz (children)

 

 

 

 

 

 

 

 

Nutramigen RTF 32 oz (infants/children)

Gerber Graduates Soy pwd 24 oz (children)

 

 

 

 

 

 

 

 

Nutramigen Enflora LGG 12.6oz powder

 

 

 

 

(children)

 

 

 

 

 

Nutren Jr. 8.45 oz , Nutren Jr. 8.45 oz w/fiber

 

 

 

 

Pediasure 1.5 RTF 8oz (children)

 

 

 

 

Pediasure 1.5w/fiber RTF 8oz (children)

 

 

 

 

Pediasure w/fiber ScFos Enteral 8oz RTF (child)

 

 

 

 

Pediasure Peptide 1.5 8oz RTF (children)

 

 

 

 

 

 

 

 

 

Neocate Splash 8oz RTF (children)

 

 

 

 

 

 

 

 

 

 

Peptamen Jr. 1.0 RTF

8.45oz Tetra pk (children)

 

 

 

 

 

 

 

 

 

 

Peptamen Jr. 1.5 RTF

8.45oz Tetra pk (children)

 

 

 

 

 

 

 

 

 

 

Periflex powder 14 oz

 

 

 

 

 

 

 

 

 

 

Phenex-1 powder 14.1 oz

 

 

 

 

 

 

 

 

 

Phenex-2 powder 14.1 oz

 

 

 

 

 

 

 

 

 

Portagen powder 16 oz (infant/children)

 

 

 

 

Pregestimil 16oz powder (infant/children)

 

 

 

 

PurAmino powder 14.1oz (infants/children)

 

 

 

 

Similac PM 60/40 powder (infant/children)

Visit: www.nmwic.org for additional information.

Rev. 2/2/2015

 

 

Similac Special Care 30cal 2oz RTF (infant)

 

 

 

IN accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, National origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Ave. SW, Washington, D.C. 20250-9410 or call toll free (866)632-9992(Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the federal relay service at (800)877-8339; or (800)845-6136(Spanish). USDA is an equal opportunity provider and employer.