All requests are subject to WIC approval which is based on program policies and procedures.
Length of issuance: the maximum allowed by federal guidelines of 6 months will be issued unless otherwise indicated.
Formula amount: the maximum amount allowed by federal guidelines (for infant/child age and feeding type) will be provided unless a decreased amount is indicated.
Name of formula: from options on reverse side.
Available formulas: available formulas are subject to change.
| Question | Answer |
|---|---|
| Form Name | New Mexico WIC Medical Request for Formula and/or Food |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 6 min |
| Edition | Revised 6/24/2026 |
| Where to send | The participant's WIC Clinic; fax is acceptable |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | WIC Rx form, NM WIC Rx form, WIC formula form, WIC medical request form, New Mexico WIC Medical Request for Formula and/or Food |
| Official source | New Mexico WIC Medical Request for Formula and/or Food (Revised 6/24/2026) |
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