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Get Pennsylvania Wic Program Prescription For Special Formula
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How to fill out the Pennsylvania WIC PROGRAM Prescription for Special Formula online
Filling out the Pennsylvania WIC Program Prescription for Special Formula can feel overwhelming, but this guide will provide clear instructions to help you navigate the process online. This comprehensive and user-friendly approach will ensure that you complete the form accurately and efficiently.
Follow the steps to complete the form with ease
- Press the ‘Get Form’ button to access the form and open it in your preferred editing application.
- Begin by entering the client’s first and last name along with their birth date in the designated fields.
- Fill in the parent or caregiver's first and last name in the corresponding section.
- Healthcare providers must respond to all bolded questions. Start with the formula or fortifier requested. Specify the amount requested per day, indicating ounces for formula or packages for fortifiers.
- Indicate the intended length of use by selecting from options for 1 month, 3 months, or 6 months. Remember that monthly renewal is required for specific formulas.
- If applicable, specify if tube feeding is required by choosing 'Yes' or 'No'.
- If there are special instructions for preparation and use, provide them in the available space.
- Next, indicate any qualifying medical conditions necessitating the prescribed formula or fortifier by entering the appropriate ICD-9 Code.
- Address restricted foods by choosing 'Yes' or 'No'. If 'Yes', check the foods that the client should not receive from WIC, and specify the length of restriction.
- Provide any additional comments, reasons, or instructions in the provided area.
- Enter the date, and have the prescribing healthcare provider sign and print their name, along with their medical office or clinic information, telephone number, and fax number.
- Once completed, you can save the document, download a copy, print it, or share it as needed.
Start completing the Pennsylvania WIC PROGRAM Prescription for Special Formula online today for a smooth application process.
Get a printout at your WIC office. Look at your store receipt from your last shopping trip. Ask a cashier or customer service person at the store to print your WIC Food Balance. Call the toll-free number on the back of your WIC Card, 1-844-4MY-FAMILY (9-3264).