Virginia WIC-395 at a glance
What it is: The WIC-395 form: if a Virginia WIC participant in your care has a diagnosed medical condition that severely impairs ingestion, digestion, absorption, or utilization of nutrients, specialized medical formulas can be requested.
Who signs: Federal regulations require this form be completed and signed by a health care provider authorized to write medical prescription under state law.
A filled-in Virginia WIC-395 example: an infant formula request
How to fill out Virginia WIC-395, box by box
INFANT FORM A. Patient Information
Enter the Infant Name and DOB, then the Parent/Guardian Name and Telephone, and mark Yes or No: Does infant have current Virginia Medicaid Coverage?
INFANT FORM B. Formula Information
Enter the Formula(s) requested. If multiple products are needed, they must ALL be included on a single form.
Is Ready-to-Feed (RTF) formula medically required? Mark Yes or No.
For Amount per day, mark Standard WIC amount or enter oz/day. For Calories per ounce, mark Standard dilution or enter kcal/oz.
For Length of use, up to 6 months, not to exceed 1st birthday, mark 1 month, 2 months, 3 months, 4 months, 5 months or 6 months.
Enter the Diagnosis with ICD code. Please refer to the first page of this form for additional details on allowable diagnoses and issuance amounts.
INFANT FORM C. Allowable WIC Supplemental Foods
Beginning at 6 months of age, WIC provides supplemental foods, in addition to prescribed formula, to infants.
Indicate any restrictions required for the duration of this prescription: Remove Infant Cereal, Remove Infant Pureed Fruits/Vegetables, Delay WIC foods until the months of age you enter, or No restrictions or infant is under 6 months of age for duration of prescription.
D. Health Care Provider Information
Enter the Printed Name and mark MD, DO, PA or NP.
Are you a Virginia Medicaid Provider? Mark Yes or No. If yes, please provide NPI #.
Enter the Clinic Name, Phone and Fax.
Sign on the Signature line and enter the Date.
More rules for Virginia WIC-395
It is very important that the WIC-395 form be fully completed and contain as much detail related to relevant diagnoses as possible to avoid delays in participants receiving the requested formula(s). In addition, it is important that requests are submitted on the page of the form that is specific to the participant category: infant, child, or woman. All requests are subject to WIC approval and to ensure compliance with federal regulations and Virginia WIC policy, additional clarification or documentation may be required before WIC staff are able to complete the approval process. Denial of a request does not imply that WIC staff question the healthcare provider's clinical judgment.
Full completion of all fields in Sections A - D required at submission. Forms with missing information will not be approved and will require resubmission.
Virginia WIC provides contract infant formulas: Similac Advance, Similac Soy Isomil, Similac Sensitive, and Similac Total Comfort. Non-contract brand formulas, such as Enfamil, Good Start, and store brands, cannot be provided. WIC-395 forms must be fully complete. Forms missing information cannot be approved and will require resubmission. The following are examples of non-qualifying conditions that will NOT be approved: colic, eczema, constipation, diarrhea, gas, fussiness, weight loss, slow or poor weight gain, non-specific feeding difficulties, spitting-up, vomiting, non-specific formula intolerances or allergies, picky eating, enhancing nutrient intake or managing body weight without a documented underlying medical condition, food intolerances or allergies that can be managed with regular foods, and preference. The medical diagnosis provided must be consistent with the requested formula. For example: prematurity would not be accepted for a hypoallergenic formula but would be appropriate to include for cases where increased caloric concentration is needed. Listing multiple comparable products on the Products Requested line is encouraged. This allows issuance flexibility in situations where there are inventory concerns. For example: Neosure/Enfacare or Neocate Jr./Equacare Jr./Alfamino Jr. Ready-to-feed (RTF) formula cannot be issued for reasons related to tolerance, convenience, or preference. WIC is a supplemental program and the formula and food benefits provided are not intended to meet the full nutritional needs of participants. Standard WIC formula amounts for infants are based on age and breastfeeding status and range from approximately 20 to 29 oz/day. For children and women, WIC can issue up to 30 oz/day. Formula amounts over the standard WIC amounts are only available for infants and children with qualifying Virginia Medicaid coverage and a qualifying diagnosis. Contract infant formulas cannot be issued in amounts over the standard WIC amount. Provision of whole or 2% milk to children over age 2 or to women is only permitted for participants who are also receiving a formula from WIC and have a diagnosis that supports increased nutritional needs. Provision of pureed fruits/vegetables after a child's 1st birthday is only permitted for participants who are also receiving a formula from WIC.
The child form and the woman form
You are filling the child form or the woman form
Enter the Child Name and DOB, then the Parent/Guardian Name and Telephone, and mark Yes or No: Does child have current Virginia Medicaid Coverage?
Enter the Name and DOB, and the Estimated Due Date or End Date of Most Recent Pregnancy.
Enter Amount per day in oz/day and mark Standard dilution or enter kcal/oz for Calories per ounce. Mark one Length of use: 1 month, 2 months, 3 months, 4 months, 5 months or 6 months.
Mark No restrictions, issue all WIC foods in addition to formula, or Provide formula only, remove ALL other WIC foods.
On the child form, to remove WIC foods, mark Remove the following WIC foods; then mark Milk/Yogurt/Cheese, 100% Juice, Cereal, Beans/Legumes, Whole Grains, Eggs, Fruits/Vegetables or Peanut Butter. To provide modifications in addition to the requested formula, mark Provide the following modifications in addition to the requested formula, then mark Pureed fruits/vegetables instead of regular fruits and vegetables, Whole milk instead of 1% and skim milk (age 2 and older, only), or 2% milk instead of 1% and skim milk (age 2 and older, only).
On the woman form, to remove WIC foods, mark Remove the following WIC foods; then mark Milk/Yogurt/Cheese, 100% Juice, Cereal, Beans/Legumes, Whole Grains, Eggs, Fruits/Vegetables, Peanut Butter or Canned Fish (available to women who are pregnant with multiples or fully breastfeeding only). To provide modifications in addition to the requested formula, mark Provide the following modifications in addition to the requested formula, then mark Pureed fruits/vegetables instead of regular fruits/vegetables, Whole milk instead of 1% and skim milk, or 2% milk instead of 1% and skim milk.
Where to get help with Virginia WIC-395
If you have questions or concerns, please visit the Healthcare Provider page at www.VirginiaWIC.com, reach out to your local WIC clinic, or contact the Virginia State WIC Office (SWO) at 877-835-5942.
Sources
[1] Virginia WIC Request for Special Prescription WIC-395 Form (3/23), Virginia Department of Health (the Official source link on this page).