Get Physician Request Form For Specialty Formula Or Nutritional ...

Completing the Physician Request Form for specialty formula or nutritional needs is essential for ensuring that patients receive the proper medical support they require. This guide will walk you through the process of filling out the form online, providing clear instructions to make the experience as seamless as possible.

Follow the steps to complete your physician request form online.

1. Click the ‘Get Form’ button to access the document and open it in your preferred viewer.
2. Begin with section A to provide the patient's information. Fill in the patient's name and date of birth, along with the parent or caregiver's name.
3. Move on to section B if medical formula or medical food is required. Enter the name of the formula ordered, the medical diagnosis, and include the ICD-9 code if available. Specify the prescribed amount per day and indicate the duration for which the medical documentation is valid.
4. In section C, outline any contraindicated supplemental foods that may be specifically relevant to the patient’s needs by marking the appropriate boxes. Provide any necessary special instructions.
5. For patients requiring soy milk or beverage alternatives, complete section D by indicating the reason for the substitute. This should specify allergies or dietary needs, excluding personal preference.
6. Proceed to section E to fill in the health care provider information. Include a signature, provider's name, professional designation, clinic name, and contact phone number.
7. Once the form is completed, save the changes, and download or print the document. You may also share it with the relevant WIC clinic or fax it using the provided contact information.

Complete your physician request form online today to ensure you meet all necessary medical needs.