This form is for official use and should only be used by Medical professionals.  The text version of this form is for accessibility purposes only.  Medical professionals should email linda.k.butler@illinois.gov to obtain a fillable/printable form.

If you have questions, please contact Linda Butler at (217) 782-2166.


WIC FORMULA AND MEDICAL NUTRITIONAL PRESCRIPTIONS

All components of this form are required and must be completed by a medical provider to receive Medically Prescribed Formulas through the WIC program. Personally identifiable information is used to determine WIC services (e.g., certification/enrollment and food package issuance) and may be disclosed to others only as allowed by state and federal laws.


Patient Last Name:

Patient First Name:

Patient Birthdate:

Parent/Caregiver Last Name:

Parent/Caregiver First Name:


PRESCRIPTION

1. Formula or Medical Nutritional Prescribed:

  • Casein Hydrolysate
    • Nutramagen w/Enflora LGG (Powder)
    • Pregestimil (Powder)
    • Alimentum
      •  Powder
      •  RTF (Corn Allergy Only)
  • Amino Acid Based
    • EleCare (Powder)
    • EleCare Junior (Powder)
    • EO28 Splash (Drink Box)
    • Neocate Infant DHA & ARA (Powder)
    • Neocate Junior (Powder)
    • Nutramigen AA (Powder)
  • Premature & Transitional
    • Enfamil EnfaCare
      •  Powder
      •  RTF
    • Similac NeoSure (Powder)
  • Other Specialized Products
    • Similac PM 60/40 (Powder)
    • Peptamen Junior (RTF)
    • Peptamen Junior w/fiber (RTF)
    • PediaSure Peptide 1.0 cal (RTF)
  • Children (over 1 year still requiring formula)
    • Enfamil AR
    • Enfamil Gentlease
    • Enfamil Premium Infant
    • Enfamil ProSobee
    • Soy Milk
      (Complete #5 and Signature Only)
  • Nutrient Dense Feedings (for women and children)
    • Boost Plus (Adults only)
    • Boost w/fiber (Adults only)
    • Ensure (Adults only)
    • Ensure Plus (Adults only)
    • Nutren Junior
    • Nutren Junior w/fiber
    • PediaSure
    • PediaSure w/fiber

2. Food Prescription

Allow age appropriate WIC Foods which may include: cereal, whole grains, milk, cheese, beans, peanut butter, eggs, infant baby foods, fruits & vegetables.

Special Instructions:

  • No solid foods: offering solids is contraindicated at this time. Please omit all supplemental foods and provide medical formula only.
  • Provide Soy milk for 6 months as part of a full WIC package due to
    • Vegan Diet/Religious Observance
    • Milk Protein Allergy
    • Severe Lactose Maldigestion (cannot tolerate lactose free milk)

3. Qualifying ICD diagnosis (if "other" ICD code required):

  • Autoimmune Disorder
  • Congenital Heart Disease
  • Congenital Anomaly, Respiratory
  • Cleft Palate
  • Cleft Lip
  • Cerebral Palsy
  • Cystic Fibrosis
  • Developmental Sensory/Motor Delays
  • Gastroesophageal Reflux
  • Hyperemesis Gravidarum
  • Immunodeficiency
  • Intestinal Malabsorption
  • Neuromuscular Disorder
  • Prematurity
  • Tube Fed
    • NPO or Pleasure feeds
    • With Food (see #2)

Other Diagnosis with ICD code (required).Federal regulations do not allow WIC to provide medical formulas based solely on the following conditions: lactose intolerance, unconfirmed allergies, managing body weight, intolerance symptoms, or growth concerns.

4. Prescribed amount:

  • Ounces per day, OR
  • Cans per day, OR
  • Maximum amount provided by WIC

5. Medical documentation valid for:

  • 1 month
  • 2 months
  • 3 months *a new prescription is required every 3 months

SIGNATURE

Health Care Provider's Signature:
(Physician, Physician Assistant or Advanced Practice Nurse Practitioner signature is required for prescriptions of the above formulas or medical foods.)

Date Signed:

Printed name of Health Care Provider:

Medical Office/Clinic:

Telephone:


In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability.  To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.