Get Utah Wic Program Formula And Food Authorization

The Utah WIC Program Formula And Food Authorization is a critical document for individuals requiring specific nutritional support. This guide will provide you with clear, step-by-step instructions on how to complete the form online effectively.

Follow the steps to fill out the Utah WIC Program Formula And Food Authorization

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. Complete section A by entering the patient’s name, date of birth, parent or guardian's name, and today’s date.
3. In section B, check all relevant medical diagnoses that apply to the patient. If there is a diagnosis not listed, write in the corresponding ICD 10 medical diagnosis.
4. For section C, specify the name and brand of the required formula or product. Indicate the physical form of the formula (powder, concentrated liquid, or ready to feed) and the daily formula amount in ounces. Ensure to select a specific quantity, avoiding ranges.
5. In section D, indicate whether WIC supplemental foods are allowed or if there are restrictions by checking the appropriate boxes.
6. For section E, indicate if whole milk should be authorized for children over 2 years old or those requiring additional calories due to a medical condition.
7. In section F, specify the duration of the issuance period by checking the desired number of months.
8. Finally, complete section G with the health care provider’s information, including their signature or stamp, clinic or hospital name, fax number, and phone number.
9. Once all sections are completed, review the form for accuracy. You can then save changes, download, print, or share the form as needed.

Complete the necessary documents online today for smoother processing.