Wic Form PDF Details

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

QuestionAnswer
Form NameWic Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswic form pdf, printable wic forms, wic arizona form, wic program arizona 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.

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 Spit-Up* o Other:

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 Spit-Up* o Enfamil ProSobee*

o Similac Go & Grow-Milk Based* o Enfagrow Toddler Transitions Soy*

o Pediasure (must meet WIC criteria for issuance) o Other:

Form of Formula: o Powder

o Concentrate o Ready-to-feed

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

 

 

 

 

 

 

 

 

 

 

 

(6-11 mo.)

Infant Jarred-fruits/vegetables

 

 

o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o

 

 

 

 

 

 

 

 

 

 

 

Children

Cow's milk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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