Get Wic Medical Documentation Form - Hawaii Department Of Health

Filling out the WIC Medical Documentation Form is an essential process for individuals seeking nutritional assistance for women, infants, and children. This guide will provide you with detailed, step-by-step instructions on how to successfully complete the form online.

Follow the steps to efficiently complete the WIC Medical Documentation Form online.

1. Click ‘Get Form’ button to access the WIC Medical Documentation Form and open it in your online editor.
2. Begin by filling out Section A, which includes patient information. Enter the patient's full name, date of birth, and the parent or caregiver’s full name. Ensure that you provide the correct medical diagnosis or qualifying condition; note that certain conditions like colic or constipation are not eligible for special formula.
3. Check the box to indicate the medical documentation's validity duration, choosing from options ranging from 1 month to 6 months.
4. Move to Section B to specify the formula information. Enter the name of the prescribed formula and the daily amount in ounces, or select the option for maximum allowable formula.
5. Proceed to Section C to select the WIC supplemental foods. Check the appropriate box to indicate whether to defer to a dietitian, issue all appropriate foods, provide formula only, or remove certain foods. Make sure to specify any supplemental foods to remove, if applicable.
6. In Section D, complete the health care provider information. The provider must sign and date the form, and you should print their name, indicate their professional designation, and provide contact details for the medical office or clinic.
7. Once all sections are completed, review the entire form for accuracy. Save your changes, and then proceed to download, print, or share the completed form as necessary.

Start filling out your WIC Medical Documentation Form online today for a smoother application process.