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Get Wic Form Arizona

Arizona WIC Special Formula Authorization Form Children Women and Healthy Infants Client Name Date of Birth WIC Client ID Please fully complete every section 1-7 to avoid delays in issuance. Amount of Formula Requested Per Day o Oral o Tube Feeding Form of Formula o Powder o Concentrate o Ready-to-feed 4. Diagnosis for Special Formula or Medical Food o Prematurity o GERD or reflux o Food allergy o Dysphagia o Failure to thrive 5th percentile wt/length or BMI/age Note Must be a specific medical diagnosis. 5. WIC Food Restrictions Please check any foods listed below that are NOT appropriate for the diagnosis. Current Formula Request WIC contract formula as noted by o Similac Advance o Similac Advance o Similac Sensitive for Fussiness Gas o Similac Total Comfort o Enfamil ProSobee o Similac for Spit-Up o Similac Go Grow-Milk Based o Other o Enfagrow Toddler Transitions Soy o Pediasure must meet WIC criteria for issuance 3. Amount of Formula Requested Per Day o Oral o Tube Feeding Form of Formula o Powder o Concentrate o Ready-to-feed 4. Please choose WIC contract formulas whenever possible as noted by. 1. Formula s Previously Tried 2. Current Formula Request WIC contract formula as noted by o Similac Advance o Similac Advance o Similac Sensitive for Fussiness Gas o Similac Total Comfort o Enfamil ProSobee o Similac for Spit-Up o Similac Go Grow-Milk Based o Other o Enfagrow Toddler Transitions Soy o Pediasure must meet WIC criteria for issuance 3. Amount of Formula Requested Per Day o Oral o Tube Feeding Form of Formula o Powder o Concentrate o Ready-to-feed 4. Diagnosis for Special Formula or Medical Food o Prematurity o GERD or reflux o Food allergy o Dysphagia o Failure to thrive 5th percentile wt/length or BMI/age Note Must be a specific medical diagnosis. 5. WIC Food Restrictions Please check any foods listed below that are NOT appropriate for the diagnosis. Note Infant 6 mo will not receive foods. o All foods are appropriate OR Category WIC Foods Do Not Give Infants 6-11 mo. Infant cereal Infant Jarred-fruits/vegetables Children 1-5 yr. and Women Exclusively Nursing Women Cow s milk Cheese Eggs Peanut butter Whole grains Cereal Beans Vegetables/fruits Juice Soy milk Tofu Canned Fish Comments Grains include the options of whole wheat bread brown rice and/or corn tortillas. 6. Length of Time Requested months circle 1 7. Print Provider Name/Title Healthcare Provider Signature o Approved OR weeks Date Phone Number Local Nutritionist/State Approval Length of Authorization From To Signature Please visit http //www. Please choose WIC contract formulas whenever possible as noted by. 1. Formula s Previously Tried 2. Current Formula Request WIC contract formula as noted by o Similac Advance o Similac Advance o Similac Sensitive for Fussiness Gas o Similac Total Comfort o Enfamil ProSobee o Similac for Spit-Up o Similac Go Grow-Milk Based o Other o Enfagrow Toddler Transitions Soy o Pediasure must meet WIC criteria for issuance 3. Amount of Formula Requested Per Day o Oral o Tube Feeding Form of Formula o Powder o Concentrate o Ready-to-feed 4. Diagnosis for Special Formula or Medical Food o Prematurity o GERD or reflux o Food allergy o Dysphagia o Failure to thrive 5th percentile wt/length or BMI/age Note Must be a specific medical diagnosis.

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