Wic Form Arizona PDF Details

The Arizona WIC (Women, Infants, and Children) Special Formula Authorization Form is a critical document designed to ensure that children, women, and infants who are part of the WIC program receive the specialized nutrition they need. This form serves as a request and authorization tool for the provision of special or medical formulas not commonly available through routine WIC benefits. It requires detailed completion, covering aspects such as formulas previously attempted, the current formula requested—highlighting WIC rebated formulas like Similac Advance* and Enfamil ProSobee*, among others—and the amount and form of formula needed, whether powder, concentrate, or ready-to-feed. Importantly, it emphasizes the medical justification for the requested formula, specifying diagnoses such as formula intolerance, food allergies, or more severe conditions like failure to thrive or severe food allergy. This form also takes into account the appropriateness of other WIC-provided foods based on the diagnosed conditions, ensuring a holistic approach to the nutritional well-being of the program's participants. Completion and approval of the form are mandatory steps for the issuance of these specialized nutritional products, highlighting the program's commitment to accommodating the diverse and specific health needs of Arizona's women, infants, and children.

QuestionAnswer
Form NameWic Form Arizona
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswic forms az, wic formula az, wic form arizona, arizona wic application form

Form Preview Example

 

 

 

 

 

Arizona WIC Special Formula Authorization Form

 

 

 

 

 

 

 

 

Children, Women and Healthy Infants

 

 

 

 

Client Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

WIC Client ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please fully complete every section (1-7) to avoid delays in issuance. Please choose WIC rebated formulas whenever possible, as noted by ‘*’.

 

1. Formula(s) Previously Tried:

 

 

 

 

 

2. Current Formula Request:

 

 

 

 

WIC contract formula:

 

 

 

 

 

o Similac Advance*

 

 

 

 

 

 

 

 

 

 

 

 

 

o Similac Advance*

 

 

 

 

 

o Similac Sensitive*

 

 

 

 

o Similac Sensitive*

 

 

 

 

 

o Similac for Spit-up*

 

 

 

 

o Similac for Spit-up*

 

 

 

 

 

o Similac Total Comfort*

 

 

 

 

o Similac Total Comfort*

 

 

 

 

 

o Enfamil ProSobee*

 

 

 

 

o Enfamil ProSobee*

 

 

 

 

 

o Enfagrow Toddler Transitions Soy*

 

 

 

 

o Other:

 

 

 

 

 

 

 

 

o Alimentum

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o Nutramigen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o Pediasure (must meet WIC criteria for issuance

 

 

 

 

 

 

 

 

 

 

 

 

 

o Other:

 

 

 

 

3. Amount of Formula Requested Per Day:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o Oral

o Tube Feeding

 

 

 

 

 

Form of Formula: o Powder

o Concentrate o Ready-to-feed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Diagnosis for routine formula (includes Similac Advance, Similac Sensitive, Similac for Spit-up, Enfamil ProSobee, and Similac Total Comfort):

o Formula Intolerance o Food allergy

o Inappropriate growth patterns

o Other:

Diagnosis for Special Formula or Medical Food:

o

Prematurity

o GERD or relux

o Dysphagia

o Failure to thrive (<5th percentile wt/length or BMI/age)

o

Severe food allergy

o Other:

 

 

 

Note: Must be a speciic medical diagnosis.

5.WIC Foods: Please check any foods listed below that are NOT appropriate for the diagnosis.

Note: Infant <6 mo will not receive foods.

oAll foods are appropriate for the client once 6 months old. OR

Category

WIC Foods

Do Not Give

Category

WIC Foods

Do Not Give

Infants

Infant cereal

 

o

Exclusively

Canned Fish

o

(6-11 mo.)

Infant Jarred-fruits/vegetables

 

o

Nursing Women

 

 

 

 

 

 

 

o

 

 

 

 

 

 

Children

Cow's milk

 

Comments:

 

 

 

(1-5 yr.)

Cheese

 

o

 

 

 

 

 

 

and Women

Eggs

 

o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Peanut butter

 

o

 

 

 

 

 

 

 

 

Whole grains**

 

o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cereal

 

o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Beans

 

o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vegetables/fruits

 

o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Juice

 

o

 

 

 

 

 

 

 

 

Soy milk

 

o

 

 

 

 

 

 

 

 

Tofu

 

o

 

 

 

 

 

 

**Grains include the options of whole wheat bread, brown rice, and/or corn tortillas.

6. Length of Time Requested:

Up to irst birthday OR # months:

 

OR # weeks:

7. Print Provider Name/Title:

 

 

 

 

Date:

 

 

 

 

 

 

Healthcare Provider Signature:

 

 

 

Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Local Nutritionist/State Approval

 

 

 

 

 

o Approved

o Not Approved

Length of Authorization: From

 

 

To

 

 

 

Comments:

Signature:

Please visit http://www.azwic.gov/physicians.htm for additional forms or information.

Revised 2/2014

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Simple tips to complete arizona wic form portion 1

2. Right after the prior part is completed, go to type in the relevant details in all these: WIC Foods Please check any foods, WIC Foods Infant cereal Infant, Category WIC Foods Exclusively, Do Not Give o, Children yr and Women, Cows milk Cheese Eggs Peanut, Comments, o o o o o o o o o o o, Grains include the options of, Length of Time Requested Up to, OR months, OR weeks, Print Provider NameTitle, Date, and Phone Number.

Filling in segment 2 in arizona wic form

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