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Get AZ WIC Special Formula Authorization Form 2014-2024

Arizona WIC Special Formula Authorization Form Children Women and Healthy Infants Client Name Date of Birth WIC Client ID Please fully complete every section 1-7 to avoid delays in issuance. Please choose WIC rebated formulas whenever possible as noted by. 1. Formula s Previously Tried 2. Current Formula Request WIC contract formula o Similac Advance o Similac Advance o Similac Sensitive o Similac Sensitive o Similac for Spit-up o Similac Total Comfort o Enfamil ProSobee o Enfagrow Toddler Transitions Soy o Other o Alimentum o Nutramigen o Pediasure must meet WIC criteria for issuance o Other 3. Amount of Formula Requested Per Day o Oral o Tube Feeding Form of Formula o Powder o Concentrate o Ready-to-feed 4. Diagnosis for routine formula includes Similac Advance Similac Sensitive Similac for Spit-up Enfamil ProSobee and Similac Total Comfort o Formula Intolerance o Food allergy o Inappropriate growth patterns o Diagnosis for Special Formula or Medical Food o Prematurity Severe food allergy GERD or reflux o Dysphagia Failure to thrive 5th percentile wt/length or BMI/age Note Must be a specific medical diagnosis. 5. WIC Foods Please check any foods listed below that are NOT appropriate for the diagnosis. Note Infant 6 mo will not receive foods. o All foods are appropriate for the client once 6 months old. OR Category WIC Foods Do Not Give Infants Infant cereal o 6-11 mo. Infant Jarred-fruits/vegetables Children Cow s milk o 1-5 yr. Cheese o and Women Eggs o Peanut butter o Whole grains o Cereal Beans Vegetables/fruits Juice Soy milk o Tofu Exclusively Canned Fish Nursing Women Comments Grains include the options of whole wheat bread brown rice and/or corn tortillas. 6. Length of Time Requested Up to first birthday OR months 7. Print Provider Name/Title Healthcare Provider Signature OR weeks Date Phone Number Local Nutritionist/State Approval o Approved Length of Authorization From To Signature Please visit http //www. Please choose WIC rebated formulas whenever possible as noted by. 1. Formula s Previously Tried 2. Current Formula Request WIC contract formula o Similac Advance o Similac Advance o Similac Sensitive o Similac Sensitive o Similac for Spit-up o Similac Total Comfort o Enfamil ProSobee o Enfagrow Toddler Transitions Soy o Other o Alimentum o Nutramigen o Pediasure must meet WIC criteria for issuance o Other 3. Amount of Formula Requested Per Day o Oral o Tube Feeding Form of Formula o Powder o Concentrate o Ready-to-feed 4. Amount of Formula Requested Per Day o Oral o Tube Feeding Form of Formula o Powder o Concentrate o Ready-to-feed 4. Diagnosis for routine formula includes Similac Advance Similac Sensitive Similac for Spit-up Enfamil ProSobee and Similac Total Comfort o Formula Intolerance o Food allergy o Inappropriate growth patterns o Diagnosis for Special Formula or Medical Food o Prematurity Severe food allergy GERD or reflux o Dysphagia Failure to thrive 5th percentile wt/length or BMI/age Note Must be a specific medical diagnosis. .

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