Get Md Wic Medical Documentation Form 2021-2025

Filling out the MD WIC Medical Documentation Form online is essential for requesting exempt infant formula or WIC-eligible nutrition. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to correctly fill out the MD WIC Medical Documentation Form online.

1. Press the ‘Get Form’ button to access the document, allowing you to open and fill out the form in the editor.
2. In Section 1, enter the required patient information. Fill in the patient’s name, parent or guardian’s name, and any optional participant medical data, such as weight, length/height, and date of measurement.
3. Proceed to Section 2, where you will request an exempt infant formula or WIC-eligible nutritional product. Check the appropriate boxes for qualifying medical conditions and specify additional details as necessary, including the product requested and daily amount.
4. In Section 3, choose the WIC food requests that apply. You can select multiple options based on the user’s eligibility and needs.
5. Complete Section 4 by providing the health care provider's details. Ensure the name, phone number, and signature are clear and legible, along with the date.
6. After completing all required sections, review the form for accuracy. Save any changes made, and proceed to download or print a copy for your records.

Complete your MD WIC Medical Documentation Form online today for timely assistance with qualifying medical nutrition needs.