Get Utah Wic Formula Form

Filling out the Utah WIC Formula Form online is a crucial step for obtaining necessary formula and food for eligible infants and children. This guide provides a detailed, step-by-step approach to help you navigate the form effectively.

Follow the steps to successfully complete the Utah WIC Formula Form online.

1. Click ‘Get Form’ button to access the online version of the Utah WIC Formula Form.
2. In Section A, enter the patient’s name, date of birth, parent or guardian name, and today’s date. Also, fill in the primary care physician and discharging physician information.
3. In Section B, check all applicable medical diagnoses for the patient. If there are conditions not listed, write them down using the ICD 10 Medical Diagnosis field.
4. In Section C, specify the name of the formula or product required. Indicate the physical form of the formula as either powder, concentrated liquid, or ready to feed. Also, state the exact amount of formula needed per day, avoiding any ranges.
5. If applicable, indicate in Section D whether WIC infant foods are permitted, keeping in mind that food availability begins at six months of age.
6. For Section E, determine and mark the length of time the formula and food authorization will be valid from the options provided.
7. In Section F, ensure the health care provider information is completed. This includes the prescriptive authority’s signature, clinic or hospital name, fax number, and phone number.
8. Once all necessary sections are filled out, you can save changes, download the form, print it, or share it as needed.

Complete the Utah WIC Formula Form online today to ensure your child's nutritional needs are met.