Get Pa Wic Program Formula Authorization Form 2016-2025

Filling out the PA WIC Program Formula Authorization Form online is a crucial step for obtaining necessary formula for individuals in need. This guide provides a clear and detailed approach to help users complete the form correctly and efficiently.

Follow the steps to complete the PA WIC Program Formula Authorization Form online.

1. Click the ‘Get Form’ button to access the PA WIC Program Formula Authorization Form and open it in your preferred editor.
2. Begin by entering the client’s first and last name along with their birth date. This information is crucial for identifying the individual who will receive the formula.
3. Fill in the parent or caregiver's first and last name to ensure that the responsible party is clearly identified.
4. In the section labeled 'Formula requested,' specify the type and amount of formula needed, including details such as ounces per day or tablespoons for modular formula. Make sure to mention the length of use—select from 1 month, 3 months, 6 months, or specify an exact date.
5. Indicate whether the formula will be administered via tube feeding by checking the appropriate box. If there are any special instructions for preparation and use of the formula, include those in the designated area.
6. Describe any qualifying medical conditions justifying the prescription of the requested formula. Be sure to include the appropriate ICD-10 code.
7. State whether there are any WIC food restrictions by selecting 'Yes' or 'No.' If 'Yes' is chosen, specify the restricted foods and duration of the restrictions.
8. If applicable, select the type of milk and yogurt authorized. Check boxes for any variations from standard offerings, such as skim, 1%, 2%, or soy beverages.
9. Include the signatures of the authorized medical professional alongside their printed name, medical office or clinic information, address, telephone, and fax number.
10. Finally, review the entire form for completeness and accuracy. Once you are satisfied, save your changes, and consider downloading, printing, or sharing the completed form as needed.

Take the next step towards obtaining the necessary formula by completing the PA WIC Program Formula Authorization Form online.