Health Care Provider

The Florida WIC Program supports the American Academy of Pediatrics’ Statement on Breastfeeding and the Use of Human Milk. Final determination of the approval and provision of formula and food will be based on Florida WIC Program policies and procedures. This form must be completed with a qualifying medical condition for infants to receive a formula other than a WIC contract formula OR for children 1 year and older or women to receive either a contract formula, other type of formula, or nutritional product. Please read the back of this form for more information about the WIC contract formulas, Florida WIC policies, and list of qualifying medical conditions. WIC policy regarding milk is at the bottom of this page. Complete all applicable fields below. Formula(s) requested, amount per day for children (1 year & older) and women, length of use, and qualifying medical condition(s) are required. Client’s Name: Date of Birth: Formula Requested: *Amount per day: ounces Formula Requested: *Amount per day: ounces

*Infants will receive the maximum monthly amount allowed by WIC regulations unless a lesser amount is requested. If more than one formula is requested, amount per day for each formula is required. Length of use in months: 1 2 3 4 5 6 7 8 9 10 11 12 Cannot exceed 12 months. Qualifying medical condition(s):

“Failure to Thrive” medical condition must be accompanied by current height/length and weight. Any special instructions: Height/Length: inches Weight: lb. oz. Date of measurement:

Check here if Licensed Dietitian/Nutritionist can determine which WIC supplemental foods to provide OR health care provider must make selections below for type of milk, foods to omit, and/or foods to modify. Standard food packages will be issued unless exceptions are checked below or contraindicated due to medical condition. Infant age 6 through 11 months: Note: Baby cereal and baby fruits/vegetables are standard WIC baby foods at this age.

formula only - no baby foods due to medical condition formula and baby cereal only

formula and all WIC baby foods formula and baby fruits/vegetables only Woman or Child 1 year & older:

Do not issue WIC supplemental foods; provide formula/nutritional product only. When prescribing formula/nutritional product, what type of milk do you want WIC to provide?

no milk whole milk 1% lowfat or fat free milk 2% reduced fat milk soy milk Select foods to omit: no yogurt no cheese no fruit juice no beans no breakfast cereal no eggs

no fruits/vegetables no whole grain foods such as bread, pasta, tortillas, brown rice, oatmeal, or bulgur

no peanut butter (only provided for women and children 2 years & older) no fish (only provided for some women) Child prescribed formula/nutritional product requires the following:

baby cereal (instead of regular breakfast cereal) baby fruits/vegetables (instead of regular fruits/vegetables) DH 3110, 1/22

Florida WIC Program

Medical Documentation for Formula and Food

Please have the client/caregiver return this completed form to the WIC office or Fax it to the WIC office. WIC Policy regarding Milk:

For child 1 year to less than 2 years old: WIC provides whole cow’s milk, whole lactose-free cow’s milk, or soy milk. WIC may provide fat-reduced milk (2%, 1% or fat free) when the child is 95th percentile weight-for-length. WIC may provide 2% reduced fat milk when the child is 85th percentile weight-for-length.

For woman or child 2 years or older: WIC provides 1% lowfat or fat free cow’s milk; 1% lowfat or fat free lactose-free cow’s milk; or soy milk. 2% reduced fat milk may be provided when a woman has a BMI < 18.5 or low prenatal weight gain/weight loss; a child is 10th percentile BMI-for- age; or the woman or child has a qualifying medical condition. Whole milk is only an option when formula/nutritional product is provided. For woman/child receiving formula/nutritional product: Health care provider may select the type of milk. Health Care Provider Information - Must print or stamp below: Address:

Phone Number:

Fax Number:

Name of Physician, APRN, or PA (print)

Signature of Physician, APRN, or PA

Date

Once approved by

WIC staff, this request

is valid for the number

of months specified

starting from the

health care provider

signature date.

Formula will be issued

as long as the request

is considered valid.

Dear Health Care Provider:

Thank you for your continuing support of the Florida WIC Program. WIC supports the American Academy of Pediatrics’ Statement on Breastfeeding and the Use of Human Milk. WIC encourages mothers to fully breastfeed their babies for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Local WIC agency staff can assist WIC mothers with breastfeeding or make appropriate referrals. The Florida WIC Program provides a limited number of milk-based and soy-based formulas for WIC infants who are not fully breastfeeding.

(See list of WIC contract formulas below.) The use of federally mandated competitive procurement for standard infant formulas has allowed the program to purchase formula at a greatly reduced cost. Use of the WIC contract formulas provides additional funds for the Florida WIC Program to serve more pregnant, breastfeeding, and postpartum women; infants; and children. Completion of this form is not needed for infants under 12 months of age to receive a WIC contract formula. WIC contract standard infant formulas are the following formulas: Note: All contract formulas have DHA & ARA. All contract formulas contain 400 IU vitamin D in 34 fl. oz. formula. Enfamil Infant milk-based formula, 60:40 whey-to-casein ratio

*Enfamil Gentlease partially hydrolyzed milk-based formula, 60:40 whey-to-casein ratio, 20% lactose

*Enfamil Reguline partially hydrolyzed milk-based formula, 60:40 whey-to-casein ratio, 50% lactose, and a blend of two prebiotics--galacto- oligosaccharide (GOS) and polydextrose (PDX)

Enfamil A.R. thickened milk-based formula, 20:80 whey-to-casein ratio Similac Soy Isomil soy protein-based formula

*These partially hydrolyzed cow’s milk-based formulas may contain a trace amount of soy protein which is used in the hydrolyzation process. WIC Program Policy for Formulas Other than the Contract Formulas

• By completing this form, you are indicating that a diagnosed qualifying medical condition necessitates the use of a different formula(s) from the current contract formulas. See list of qualifying medical conditions as described below. All requests are subject to WIC approval.

• It is our policy to re-evaluate the client’s continued need for the formula(s) on a periodic basis during the requested time period. Based on our evaluation, the health care provider may be contacted for updated information for the approval to continue.

• If a formula request expires, WIC’s policy is to provide the following unless a new request is received: Infants under 12 months of age will be offered a contract formula food package. Women and children (1 year & older) will be offered a standard food package once request expires.

• In some cases, incomplete or limited medical information may prevent the approval of the formula(s) requested. In order to expedite the approval process, WIC staff may need to contact the health care provider to obtain more detailed medical information. Health care provider contact information is required on the front of the form. Qualifying Medical Conditions – formula approvals will be considered for one or more of these reasons:

Non-qualifying Conditions – formulas will not be

approved solely for one or more of these reasons:

• Premature birth will be considered a qualifying medical condition for children under 12 months of age (adjusted age) to receive a premature formula.

• Low birth weight will be considered a qualifying medical condition for infants under 6 months of age (adjusted age) to receive a high calorie formula.

• Neonatal Abstinence Syndrome (NAS) for infants under 6 months of age.

• Inborn errors of metabolism and metabolic disorders.

• Specific gastrointestinal disorder or malabsorption syndrome that impairs ingestion, digestion, absorption, or utilization of nutrients that could adversely affect nutritional status.

• GER or GERD only with an additional qualifying medical condition/complication.

• Immune system disorders.

• Specific life-threatening disorders, diseases, or conditions.

• Specific protein allergy or intact protein sensitivity/intolerance requiring an extensively hydrolyzed formula or amino acid based formula.

• Failure to Thrive only when the child is documented with one or more of the following: at or below 5th percentile weight-for-length on WHO growth charts for ages under 24 months OR at or below 5th percentile BMI-for-age on CDC Growth Charts for ages 24 months and older OR both the length/height for age and weight for age are at or below the 5th percentile OR has dropped one growth channel in a 6-month time period which results in the child being below the 25th percentile weight-for-length or BMI-for-age. Current anthropometric data required.

• Colic, spitting up, gassiness, or fussiness.

• Diarrhea, vomiting, or constipation that is of short duration or intermittent.

• “Feeding difficulty” without giving medical diagnosis.

• “Medically necessary” without giving medical

diagnosis.

• “Poor weight gain” without giving medical diagnosis.

• Enhancing nutrient intake or managing body weight.

• Non-specific formula or food intolerance.

• Preference.

• Uncomplicated GER/GERD.

• Lactose intolerance for women and children who

can tolerate lactose free milk or soy milk (soy-based beverage).

WIC is a supplemental nutrition program. WIC does not provide all of the formula or food needed by program participants. For information on standard WIC food packages, refer to FloridaWIC.org website under the WIC Program Information tab, WIC Foods section. If you have a question about a specific formula, please contact your local WIC office or the Florida WIC Program at 1-800-***-****. This institution is an equal opportunity provider. Age in Months WIC Maximum Monthly Formula Amount** birth to 3 months 870 fl. oz.

4 to 5 months 960 fl. oz.

6 to 11 months 696 fl. oz.

12 months and older 910 fl. oz.

**Monthly amounts will vary depending upon formula packaging and product type (powder, concentrate, or ready-to-use formula), and if infant is breastfed.

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