Get Wic Formula And Food Authorization Form - Utah County - Utahcountyonline

The WIC Formula And Food Authorization Form is essential for obtaining authorized food and formula for infants and eligible individuals. This guide outlines the process to fill out the form accurately, ensuring that you understand each section and field to facilitate a smooth application.

Follow the steps to complete the WIC Form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing section A, which includes the patient’s name, date of birth, parent or guardian name, and today’s date. Ensure all information is accurate to avoid processing delays.
3. In section B, check all applicable medical diagnoses for the patient. If additional diagnoses are present that are not listed, write in the appropriate ICD 10 Medical Diagnosis.
4. For section C, specify the name and brand of the formula or product required. Indicate whether the formula is in powder, concentrated liquid, or ready-to-feed form. Additionally, provide the specific quantity of formula needed per day, avoiding range indications.
5. In section D, indicate whether WIC complementary foods are desired or if there are restrictions. Remember that these foods are generally provided to infants aged 6 months and older.
6. Next, fill out section E to specify the number of months for which the formula and food authorization is valid. If no options are marked, 6 months will be issued, including the current month.
7. In section F, the health care provider must provide their information and a signature to validate the authorization. Ensure that this is completed by a Utah state licensed prescriptive authority.
8. Review the entire form for completeness and accuracy. Once all sections are filled out, you can save changes, download, print, or share the completed form as needed.

Complete your documents online to ensure timely access to WIC services.