Get Az Wic Special Formula Authorization Form 2014-2025
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How to fill out the AZ WIC Special Formula Authorization Form online
Completing the AZ WIC Special Formula Authorization Form is essential for ensuring that individuals receive the appropriate nutritional support. This guide provides clear and detailed instructions on filling out the form online, ensuring a smooth and efficient submission process.
Follow the steps to fill out the AZ WIC Special Formula Authorization Form easily
- Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
- Enter the client name and date of birth in the designated fields at the top of the form. This information should reflect the individual for whom the formula request is being made.
- Fill in the WIC client ID to ensure the form is linked to the correct individual within the WIC system.
- In section 1, list any formulas that have been previously tried to provide context for the current request.
- In section 2, select the current formula request from the available options. Ensure to highlight any WIC rebated formulas that are marked with an asterisk (*) for eligibility.
- Specify the amount of formula requested per day in section 3, along with the preferred form of formula, such as powder, concentrate, or ready-to-feed.
- In section 4, provide the diagnosis for routine formula and any specific medical diagnosis for special formulas or medical foods. Make sure to choose the appropriate options that align with the individual’s medical needs.
- In section 5, identify any foods that are not appropriate for the individual’s diagnosis. Check the boxes next to the food categories that should not be given.
- Indicate the length of time for which the authorization is requested in section 6, specifying either 'up to first birthday' or the exact number of months.
- Complete section 7 by entering the print provider name/title and obtaining the healthcare provider's signature along with the date and phone number.
- Finally, review the completed form for accuracy, then save the changes, download, print, or share the form as needed.
Complete the AZ WIC Special Formula Authorization Form online today to ensure timely processing of nutritional support.
AHCCCS covers a wide range of services for children, including routine check-ups, immunizations, dental care, and hospital services. These benefits ensure that children receive essential healthcare, promoting their well-being. Parents can discover specific covered services by visiting the AHCCCS website or contacting their local office for more detailed information.
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