Physician Authorization/Medical Documentation

A healthcare professional licensed to write medical prescriptions is required to provide the following medical documentation:

• Medical determination of a qualifying condition;
• Name of the prescribed WIC formula;
• Quantity needed per day of prescribed WIC formula;
• Length of time the WIC formula is required by the participant;
• Indication of supplemental food restrictions or contraindications; and
• Signature of healthcare professional, date, and contact information.

 

Physician Authorization/Medical Documentation Form