WIC-395 Form PDF Details

The Commonwealth of Virginia's Department of Health extends a focused effort towards promoting breastfeeding through its Women, Infants, and Children (WIC) Program, while also acknowledging the necessity for formula feeding in certain scenarios. With an exclusive contract with Abbott Nutrition, Virginia WIC mandates the use of Similac Advance and Similac Soy Isomil for formula-fed infants, restricting the utility of formulas from other manufacturers unless medically warranted. When a specialized formula or food is deemed necessary for medical reasons, healthcare professionals are encouraged to fill out the Virginia WIC 395 form to request a special food prescription for the infants, children, and women under their care. Accommodating the nutritional needs and medical conditions of each participant, the form facilitates a process to ensure that all eligible individuals receive not only the specialized nutritional products they require but also continue to have access to standard WIC supplemental foods. This process is upheld through rigorous protocols, requiring the renewal of the WIC-395 form at each certification appointment or whenever a change in the prescription is necessary, ensuring the program's adaptability to the evolving health needs of its participants. Details regarding formula issuance, including Ready To Feed (RTF) options, standard formula amounts, and policy-driven exceptions, are meticulously outlined, providing clear guidance for healthcare providers. This structure underscores Virginia WIC’s commitment to supporting the health and nutrition of vulnerable populations by bridging the gap between medical necessity and nutritional assistance.

QuestionAnswer
Form NameWIC-395 Form
Form Length3 pages
Fillable?Yes
Fillable fields148
Avg. time to fill out30 min 25 sec
Other namesform wic 395 form, wic 395, wic 395 form virginia, wic form 2021

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COMMONWEALTH OF VIRGINIA

Department of Health

Dear Heath Care Professional:

The Virginia Women, Infants, and Children (WIC) Program promotes breastfeeding as the optimal feeding method for infants. For those infants who do consume formula, Similac Advance and Similac Soy Isomil are offered. A contract with Abbott Nutrition for these formulas provides a special price that allows the WIC program to serve more participants in Virginia. Due to this contract, Virginia WIC is unable to provide standard infant formulas which are made by other manufacturers (ex. Mead Johnson (Enfamil), Nestle (Gerber Good Start), or generic/store brands).

Medical conditions may require the use of special formulas for infants and the use of special formula, nutritionals, and/or modified food benefits for children and women. If a Virginia WIC participant in your care requires one of these items, a special food prescription can be issued after the completion of this WIC-395 request form. All participants receiving a special food prescription remain eligible to receive age/category appropriate WIC supplemental foods as medically indicated.

A new WIC-395 request form is required at each WIC subsequent certification appointment or at the end of the duration indicated, whichever occurs first. In addition, a new request form will also be required when any changes to the food prescription are requested.

The current Virginia WIC Formulary of approved Formulas/Nutritionals can be found at:

http://www.vdh.virginia.gov/wic-participants/food-packages-and-infant-formula/

Further details about issuance of Ready To Feed (RTF) formula can be found at:

http://www.vdh.virginia.gov/content/uploads/sites/42/2017/01/FDS-03.2-C.pdf

In addition, please refer to the provided chart below for the standard issuance amounts of WIC provided formulas/nutritionals.

Standard WIC Formula/Nutritional Amounts

Participant

Infants

Infants

Infants

Children and

Category

0-3 months

4-5 months

6-11 months

Women

Monthly Formula

Up to 806 fl oz

Up to 884 fl oz

Up to 624 fl oz

Up to 910 fl oz

Amount

Approximately

Approximately

Approximately

Approximately

 

(Reconstituted)

26 fl oz/day

29 fl oz/day

20 fl oz/day

30 fl oz/day

For more information about special food prescriptions or formula issuance by the Virginia WIC program, please contact the State WIC Office at (804) 864-7800 or your local office at: ____________________________________________________.

USDA is an equal opportunity provider, employer, and lender

WIC-395 (10/17)

Virginia Request

for Special Food Prescription

WIC-395

Prescription is subject to approval and provision based on Virginia WIC policy and procedure.

A. Patient Information

Participant’s Name:

 

 

Date of Birth:

 

 

 

Parent/Caregiver’s First and Last Name:

 

 

 

 

 

B. Current Anthropometric Data

 

 

 

 

 

 

Weight:

Length/Height:

Hgb/Hct:

Date Assessed:

 

 

 

 

For intolerances to Similac Advance and/or Similac Soy Isomil due to lactose sensitivity, excessive spit-up, or digestive issues, the following 19 kcal/oz contract infant formulas are available:

C. Alternative Routine Infant Formulas

Similac Sensitive Powder

Similac Spit-up Powder

Similac Total Comfort Powder

Similac Sensitive RTF*

Similac Spit-up RTF*

*RTF products require additional justiication and issuance is subject WIC Policy

If none of the above formulas are appropriate for the participant or if a food prescription modiication is required, please complete the following:

D. Exempt Infant Formulas/Nutritionals

Product Name: _________________________________________________________________________________________

Form: Powder

Concentrate

RTF* *RTF products require additional justiication and issuance is subject WIC Policy.

Diagnosis: _____________________________________________

ICD Code: _________________________________

Symptoms such as colic, constipation, spitting-up, gas, and/or formula intolerance will NOT be accepted. WIC will not provide formula to enhance nutrient intake or manage body weight without underlying medical condition.

Calories Per Ounce:

Standard Dilution

OR

____________ kcal/oz

Ounces Per Day:

Standard WIC Amount (Infants Only)

OR

_____________ oz*

*Amounts above the standard WIC maximum are only allowable for participants who meet both Medicaid Coverage and Diagnosis Criteria

E. WIC Supplemental Foods

Issue Full Provision of Age-Appropriate Foods

Issue NO WIC Supplemental Foods, Provide Formula/Nutritional ONLY

Issue Supplemental Foods with the Modiications Below:

Infants

Provide formula only due to inability to consume solids

Omit Infant Cereal

Omit Infant Fruits Vegetables

Omit Infant Meats

Children and Women

Provide Infant Pureed

Provide Whole Milk,

Provide 2% Milk,

Fruits/Vegetables

ICD Code Required:

ICD Code Required:

(Formula Use Required)

________________

________________

Omit Peanut Butter

Omit Milk/Cheese/Yogurt

Omit Whole Grains

Omit Beans

Omit Eggs

Omit Fruits/Vegetables

Omit Breakfast Cereal

Omit Juice

Omit Tuna/Salmon

F. Length of Use

 

Duration of Certiication, up to 1 year

OR

______________ months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G. Health Care Provider’s Information (print or stamp)

 

 

“WIC USE ONLY”

 

Provider Name:

 

 

 

 

 

 

Family ID #:

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CPA Signature:

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax:

 

 

 

 

 

 

CPA Name:

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Health Care Professional authorized

Date

 

 

 

 

 

 

 

 

 

to write medical prescriptions under State law.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USDA is an equal opportunity provider, employer, and lender.

WIC 395 ( Rev. 10/17)

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