Get Alaska Wic Nutrition Program Enpr Form - Effective October 1, 2015 - Dhss Alaska

Filling out the Alaska WIC Nutrition Program ENPR Form is essential for ensuring eligible individuals receive the necessary nutritional support. This guide will provide you with clear, step-by-step instructions to successfully complete this important form online.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the ENPR form and open it for completion.
2. Begin by entering the client's name and date of birth in the designated fields. This information ensures the form is correctly associated with the appropriate individual.
3. Next, provide the name of the parent or caregiver along with their phone number for contact purposes. This is crucial for communication regarding the nutritional needs of the client.
4. Indicate whether the client is Medicaid eligible by checking the corresponding box and entering their Medicaid number and its end date if applicable.
5. Record the current measurements, including height and weight, in the fields provided. If available, include the medical date as well.
6. For infants, specify the prescribed formula and the maximum allowable ounces. If another formula was tried, provide its name and check the appropriate box for any foods to avoid.
7. For children and women, similarly specify the prescribed formula along with the amount, and any additional milk type to be included. Indicate if any age-appropriate WIC foods are allowed.
8. Fill out the medical diagnosis and corresponding ICD-10 code accurately, as both are required for processing the request.
9. Have the healthcare provider complete their signature, name, address, and phone number. Ensure that their Medicaid ID is also included.
10. Once all fields are completed, review the form for accuracy. Finally, save changes, download, print, or share the form as necessary.

Complete the Alaska WIC Nutrition Program ENPR Form online today to ensure nutritional support for eligible individuals.