In this blog post, we're going to be discussing WIC forms. We'll go over what they are and how to fill them out correctly. If you're a WIC recipient, then it's important that you know how to properly complete these forms so that you can get the most out of the program. If you're not familiar with WIC, keep reading – we'll introduce you to this valuable resource for low-income families. WIC is a government-funded nutrition program that provides assistance to pregnant women, new mothers, and children up to age 5. The program offers vouchers for specific foods and supplements, as well as nutrition education and counseling. To learn more about WIC and how to apply for benefits, visit our website or
Question | Answer |
---|---|
Form Name | Wic Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | wic form pdf, printable wic forms, wic arizona form, wic program arizona form |
|
|
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.Formula(s) Previously Tried:
WIC contract formula as noted by ‘*’: o Similac Advance*
o Similac Sensitive for Fussiness & Gas* o Similac Total Comfort*
o Enfamil ProSobee* o Similac for
3. Amount of Formula Requested Per Day:
o Oral |
o Tube Feeding |
Please choose WIC contract formulas whenever possible, as noted by ‘*’.
2.Current Formula Request: o Similac Advance*
o Similac Sensitive for Fussiness & Gas* o Similac Total Comfort*
o Similac for
o Similac Go &
o Pediasure (must meet WIC criteria for issuance) o Other:
Form of Formula: o Powder |
o Concentrate o |
4. 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 |
Food allergy: |
|
o Other: |
|
|
|
|
|
Note: Must be a speciic medical diagnosis.
5.WIC Food Restrictions: Please check any foods listed below that are NOT appropriate for the diagnosis.
Note: Infant <6 mo will not receive foods.
o All foods are appropriate OR |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
Category |
WIC Foods |
Do Not Give |
|
Comments |
|
|
|
|
||||||||||||
Infants |
Infant cereal |
|
|
o |
|
|
|
|
|
|
|
|
|
|
|
|||||
Infant |
|
|
o |
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
o |
|
|
|
|
|
|
|
|
|
|
|
|
Children |
Cow's milk |
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
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 |
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
o |
|
|
|
|
|
|
|
|
|
|
|
||
Exclusively |
Canned Fish |
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
Nursing Women |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
**Grains include the options of whole wheat bread, brown rice, and/or corn tortillas. |
|
|
|
|
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
6. Length of Time Requested: # months (circle): 1 |
2 3 |
4 |
5 |
6 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 10/2013 |