Get Nh Wic Program Formulas And Special Medical Bb - Northwood Inc

Filling out the NH WIC Program Formulas And Special Medical Bb - Northwood Inc form online is an important step for users seeking special formulas and supplemental foods. This guide offers clear, step-by-step instructions to ensure the process is straightforward and effective.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out Section A, which requires the patient's information including their name, date of birth, parent or caregiver's name, and Medicaid number. Ensure this information is accurate to avoid delays.
3. In Section A, provide the medical reason or diagnosis, along with the corresponding ICD9 code. This is important as it serves as the basis for the medical necessity of the formula requested.
4. Select the time needed for the special formula from the provided options, indicating whether it is necessary for 1 to 6 months.
5. Proceed to Section B to specify the special formula and WIC supplemental foods required. Choose the formula from the approved list and indicate the prescribed amount.
6. If necessary, provide special instructions or comments regarding the nutritional needs.
7. Indicate any contraindications to the provision of supplemental foods in Section B. This includes checking the appropriate boxes for infants, children, or women.
8. Complete Section C if requesting soy beverages, tofu, or additional cheese, checking the relevant boxes based on the patient's dietary needs.
9. In Section D, ensure a healthcare provider's signature is included, along with their printed name, credentials, medical office information, and contact phone number.
10. After all sections have been completed, save the changes. You can then download, print, or share the form as necessary.

Complete your NH WIC Program Formulas And Special Medical Bb - Northwood Inc form online today for efficient processing.