Get Wic Medical Documentation Form - Hawaii Department Of Health

This guide provides comprehensive instructions for users looking to complete the WIC Medical Documentation Form for the Hawaii Department of Health online. Following these steps will help ensure that all necessary information is accurately provided to meet the requirements of the program.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your editor. Ensure you have a suitable application or tool to fill out digital forms.
2. Complete section A, which requires patient information. Enter the WIC clinic, phone number, and fax number, along with the patient’s name (last, first, middle initial) and date of birth. Include the name of the parent or caregiver and document the medical diagnosis or qualifying condition. Remember that conditions like colic or formula intolerance do not qualify.
3. In section B, specify the name of the special formula or WIC-approved medical food requested and indicate the prescribed amount in ounces per day or select 'maximum allowable' if applicable.
4. Proceed to section C to choose the supplemental foods category. You can select 'all' for all age-appropriate foods, 'none' for formula-only, or 'modified' to remove specific supplemental foods. Check the appropriate boxes for the foods to be removed if necessary.
5. If applicable, fill out section D for soy beverage, tofu, or cheese. Indicate the reason for the substitution based on specified medical, dietary, or cultural preferences.
6. Complete section E by providing health care provider information. This includes their signature, date, printed name, professional designation, medical office or clinic information, and contact details.
7. After filling out all relevant sections, review the form for accuracy and completeness. You can then save changes, download the completed form, print it if needed, or share it as required.

Complete your WIC Medical Documentation Form online today to ensure timely assistance.