The Illinois WIC Program uses the WIC Formula and Medical Nutritional Prescriptions Form as its method for communicating and documenting special formula/food needs from the medical home to the WIC agency.

All areas of the form must be completed by a physician or other licensed health care professional authorized to write medical prescriptions under state law and are valid for a maximum of 3 months.


  • This form is for official use and should only be used by Medical professionals.
  • Medical professionals should email Stephanie Bess to obtain a fillable/printable copy of this form.



If you have questions, please contact the Bureau of Family Nutrition at (217) 782-2166.