Skip Navigation LinksWyoming Department of Health Community and Public Health Division WIC Phyisican Authorization/Medical Documentation

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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

updated 11/2015