Get Wic Medically Necessary Formula Request - New Dhh Louisiana

This guide provides clear, step-by-step instructions for completing the WIC Medically Necessary Formula Request form online. Designed for a broad audience, this resource aims to make the process as straightforward as possible.

Follow the steps to successfully complete the WIC Medically Necessary Formula Request form.

1. Press the ‘Get Form’ button to access the WIC Medically Necessary Formula Request form and open it in your document editor.
2. Begin by entering the patient's information in the designated fields, including their name, date of birth, weight, length/height, hemoglobin, hematocrit, and weeks of gestation. Ensure all entries are accurate and complete.
3. Next, specify the medical diagnosis or qualifying condition that justifies the need for the formula or food. Include the corresponding ICD-9 code for precise identification.
4. Indicate the name of the requested WIC formula or medical food. You must also check the box for the maximum allowed amount or specify the daily quantity required.
5. Provide any special instructions or contraindications related to supplemental foods. Indicate if supplemental food is contraindicated, or if all appropriate WIC supplemental food should be provided.
6. Once all necessary sections are filled out, have the licensed healthcare professional sign and date the form. Include their contact information for any follow-up questions.
7. Confirm that the completed form is less than 60 days old before submitting. Submit the form via fax or hand-delivery to the clinic staff for processing.
8. After submission, the WIC staff will review the request and complete their section, providing approval and duration of the formula if granted. Retain a copy for your records.

Complete your WIC Medically Necessary Formula Request online today to ensure timely approval.