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The Arizona WIC Special Formula Authorization Form is a document designed to assist in the provision of specialized formula for eligible women, infants, and children. This form must be completed thoroughly to ensure timely processing and approval of formula requests. It includes sections for previous formulas tried, current formula requests, and necessary medical diagnoses.

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Overview

The Arizona WIC Special Formula Authorization Form plays a crucial role in ensuring that eligible women, infants, and children receive the nutritional support they need. This form is designed for healthcare providers to facilitate the request for specialized formula that meets the specific dietary needs of their patients. It consists of several sections that gather essential information, such as the client’s name, date of birth, and WIC Client ID, which are vital for processing the request without delays. The form allows providers to specify previous formulas tried, current formula requests—including WIC-rebated options—and the amount of formula needed per day, whether for oral consumption or tube feeding. Additionally, it requires healthcare professionals to provide a diagnosis justifying the need for routine or special formula, ensuring that the request is medically sound. The form also includes a section for WIC-approved foods, where providers can indicate any foods that should be avoided based on the client’s diagnosis. Finally, the length of time for which the formula is requested can be specified, along with the provider’s signature for verification. By following the guidelines laid out in this form, healthcare providers can help ensure that their clients receive the necessary nutritional support in a timely manner.

Please fully complete every section (1-7) to avoid delays in issuance. Please choose WIC rebated formulas whenever possible, as noted by ‘*’.

1.Formula(s) Previously Tried:

WIC contract formula: o Similac Advance* o Similac Sensitive* o Similac for Spit-up* o Similac Total Comfort* o Enfamil ProSobee* o Other:

3. Amount of Formula Requested Per Day:

o Oral

o Tube Feeding

2.Current Formula Request: o Similac Advance*

o Similac Sensitive* o Similac for Spit-up* o Similac Total Comfort* o Enfamil ProSobee*

o Enfagrow Toddler Transitions Soy* o Alimentum

o Nutramigen

o Pediasure (must meet WIC criteria for issuance o Other:

Form of Formula: o Powder

o Concentrate o Ready-to-feed

4. Diagnosis for routine formula (includes Similac Advance, Similac Sensitive, Similac for Spit-up, Enfamil ProSobee, and Similac Total Comfort):

o Formula Intolerance o Food allergy

o Inappropriate growth patterns

o Other:

Diagnosis for Special Formula or Medical Food:

o	Prematurity	o GERD or relux		o Dysphagia	o Failure to thrive (<5th percentile wt/length or BMI/age)
o	Severe food allergy	o Other:

Note: Must be a speciic medical diagnosis.

5.WIC Foods: Please check any foods listed below that are NOT appropriate for the diagnosis.

Note: Infant <6 mo will not receive foods.

oAll foods are appropriate for the client once 6 months old. OR

Category	WIC Foods	Do Not Give		Category	WIC Foods	Do Not Give
Infants	Infant cereal		o	Exclusively	Canned Fish	o
(6-11 mo.)	Infant Jarred-fruits/vegetables		o	Nursing Women
			o
Children	Cow's milk		o	Comments:
(1-5 yr.)	Cheese		o
and Women	Eggs		o
and Women	Eggs		o
	Peanut butter		o
	Whole grains**		o
	Whole grains**		o
	Cereal		o
	Cereal		o
	Beans		o
	Beans		o
	Vegetables/fruits		o
	Vegetables/fruits		o
	Juice		o
	Soy milk		o
	Tofu		o

**Grains include the options of whole wheat bread, brown rice, and/or corn tortillas.

6. Length of Time Requested:

Up to irst birthday OR # months:

OR # weeks:

7. Print Provider Name/Title:

Date:

Healthcare Provider Signature:

Phone Number:

Local Nutritionist/State Approval

o Approved

o Not Approved

Length of Authorization: From

Comments:

Signature:

Please visit http://www.azwic.gov/physicians.htm for additional forms or information.

Revised 2/2014

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Fact Name	Details
Form Purpose	The Arizona WIC Special Formula Authorization Form is used to request specific formulas for children and women in the WIC program.
Required Information	Clients must complete all sections (1-7) of the form to prevent delays in formula issuance.
WIC Formulas	WIC encourages the use of rebated formulas, indicated with an asterisk (*), to optimize resources.
Diagnosis Requirement	A specific medical diagnosis is required for special formulas or medical foods, ensuring appropriate nutritional support.
Governing Law	This form is governed by the Arizona Department of Health Services WIC Program regulations.

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Arizona WIC Special Formula Authorization Form

Children, Women and Healthy Infants

Client Name:

Date of Birth:

WIC Client ID:

Date of Birth:

WIC Client ID:

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