Get Special Issuance Authorization Form - Kansas Wic - Kdheks

The Special Issuance Authorization Form for the Kansas WIC Program is essential for requesting special infant formulas and medical foods necessary for eligible individuals. This guide provides clear and comprehensive instructions to assist users in completing the form accurately and efficiently online.

Follow the steps to complete the Special Issuance Authorization Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the 'Client Name' and 'Date of Birth' fields. Ensure that the information is accurate as it will be used for identification.
3. Enter the 'Parent/Guardian Name' to ensure proper authorization for the request.
4. In the section labeled 'Authorization requested for,' specify the formula or medical food by writing the brand name of the product requested.
5. Select the 'Length of Time Product Required' by checking the appropriate box, either 'until 1 year old' or 'until next WIC certification (generally 6 months).'
6. Indicate the 'Daily Amount Required' by filling in the requested quantity, recognizing that WIC may not be able to issue all that is requested.
7. Provide a diagnosis in the 'Acceptable Diagnoses' section that supports the request for the product. This is crucial for authorization.
8. Review and confirm that no unauthorized symptoms or preferences are cited in the specified section related to issuance.
9. The health care professional should sign and date the form in the provided fields, ensuring their printed name and telephone number are included.
10. Once all fields are completed, save your changes, download the form, print it for submission, or share it as required.

Complete your documents online for a smooth submission process.