Get Ga Medical Documentation Form For Wic Special Formulas And Wic Foods 2009-2025

Filling out the GA Medical Documentation Form for WIC Special Formulas and WIC Foods online is essential for obtaining the necessary nutritional support for eligible individuals. This guide provides clear instructions on each section of the form, ensuring that you can complete it accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, enter the patient's first and last name along with their date of birth in MM/DD/YY format. Then, provide the parent or caregiver’s first and last name.
3. Next, list the qualifying medical condition(s) along with the corresponding ICD-9 or ICD-10 code(s) justifying the special formula or medical food prescription.
4. In the 'Special Formula Requested' section, indicate the name of the requested formula or medical food and specify the prescribed amount per day in ounces. Select the form type (powder, concentrate, or ready-to-feed) and include any special instructions or comments along with the planned length of use.
5. Proceed to the WIC Foods section. You must choose between section A or B. If there are no food restrictions, initial the line indicating 'No Supplemental Food Restrictions'. If there are restrictions, indicate the contraindicated supplemental foods and provide any additional comments.
6. Complete the Health Care Provider Information section, including the provider’s name, title, signature, date, medical office or clinic name, address, phone number, and fax number. Ensure that the original signature is included, as stamped or proxy signatures will not be accepted.
7. After all sections are completed, review the document for accuracy. You can then save changes, download, print, or share the form as needed.

Start filling out your GA Medical Documentation Form online now to ensure timely access to WIC special formulas and foods.