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Alabama WIC Infant Formula Prescription Prescription is subject to WIC Approval based on Program Policy and Procedure Date Infant s Name Date of Birth ICD-10 Code and/or Medical Diagnosis Not WIC Approved Colic Spitting up Fussiness Constipation or Formula Intolerance Formula Prescribed Must Indicate Amount Per Day Maximum ounces allowed by WIC for Fully Formula Fed Infant 0-3 mos - 26 fluid oz/day 4-5 mos - 29 fluid oz/day 6-12 mos - 20 fluid oz /day Infant needs lesser amount amount is oz per day Intended length of use 6 months - At 6 months of age a new prescription is required. Exception In disease/chronic diseases such as but not limited to inborn errors of metabolism galactosemia celiac disease and cystic fibrosis the initial prescription is sufficient. - If the prescription is not renewed a standard contract formula will be issued* - Re-evaluating the infant s need for a special formula past 6 months of age ensures that WIC funds are utilized in the most cost effective way. Notice The standard contract formulas are Similac Advance Similac Isomil* Other milk based soy based and milk based lactose free formulas are not WIC approved* Supplemental Foods Infant cereal Not Allowed Infant vegetables and fruits This infant 6-12 months of age is medically fragile and unable to consume solid food. I authorize additional formula total 29 oz/day to meet nutritional needs. Signature of Health Care Provider Provider s Name Please print Phone Fax If you have questions please call your local WIC clinic* WIC Clinic Use Only ParticipantID Date Received Approved by ADPH-WIC-111a-9-15. - If the prescription is not renewed a standard contract formula will be issued* - Re-evaluating the infant s need for a special formula past 6 months of age ensures that WIC funds are utilized in the most cost effective way. Notice The standard contract formulas are Similac Advance Similac Isomil* Other milk based soy based and milk based lactose free formulas are not WIC approved* Supplemental Foods Infant cereal Not Allowed Infant vegetables and fruits This infant 6-12 months of age is medically fragile and unable to consume solid food. Notice The standard contract formulas are Similac Advance Similac Isomil* Other milk based soy based and milk based lactose free formulas are not WIC approved* Supplemental Foods Infant cereal Not Allowed Infant vegetables and fruits This infant 6-12 months of age is medically fragile and unable to consume solid food. I authorize additional formula total 29 oz/day to meet nutritional needs. Signature of Health Care Provider Provider s Name Please print Phone Fax If you have questions please call your local WIC clinic* WIC Clinic Use Only ParticipantID Date Received Approved by ADPH-WIC-111a-9-15. - If the prescription is not renewed a standard contract formula will be issued* - Re-evaluating the infant s need for a special formula past 6 months of age ensures that WIC funds are utilized in the most cost effective way. Notice The standard contract formulas are Similac Advance Similac Isomil* Other milk based soy based and milk based lactose free formulas are not WIC approved* Supplemental Foods Infant cereal Not Allowed Infant vegetables and fruits This infant 6-12 months of age is medically fragile and unable to consume solid food. I authorize additional formula total 29 oz/day to meet nutritional needs. Signature of Health Care Provider Provider s Name Please print Phone Fax If you have questions please call your local WIC clinic* WIC Clinic Use Only ParticipantID Date Received Approved by ADPH-WIC-111a-9-15.