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 to obtain a fillable/printable form.

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


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:


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


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:


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.