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Get WIC Prescriptions And Clinical Data Form For Infants - Wisconsin ... - Dhs Wisconsin

TA INFANTS (birth through 12 months of age) Completion of the PRESCRIPTION section is required for WIC-approved exempt formulas (Fed. Reg. 246.10). Completion of CLINICAL DATA is voluntary. Personally identifiable information is used to determine WIC services and may be disclosed only as allowed by state and federal laws. INSTRUCTIONS: To provide clinical data (to facilitate WIC enrollment), complete the Clinical Data section. To prescribe an exempt Wisconsin WIC-approved formula, complete Presc.

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