The New Mexico WIC Prescription form is a crucial document used to request specialized formula or food for eligible participants in the Women, Infants, and Children (WIC) program. This form helps ensure that individuals with specific medical conditions receive the nutritional support they need. Understanding how to fill it out properly can facilitate access to essential resources for families in New Mexico.
The New Mexico WIC Prescription form is a vital document designed to facilitate the provision of specialized nutritional support for women, infants, and children in need. This form plays a crucial role in ensuring that eligible participants receive the appropriate medical formula and food based on specific health conditions. It requires essential patient information, including the patient's name, date of birth, and qualifying medical diagnosis, which must be confirmed by a healthcare provider. The form also allows for detailed requests regarding the type and amount of formula needed, catering to various conditions such as allergies, metabolic disorders, or developmental delays. Furthermore, it outlines the necessary steps for healthcare providers to complete the form, ensuring compliance with WIC program policies. By following the instructions provided, families can access the nutritional support they require, which is essential for healthy growth and development.
New Mexico WIC Medical Request for Formula/Food
Directions for completing this form and other information are on reverse side.
All requests are subject to WIC approval and provision based on program policy and procedure
A. Required Patient Information
Patient’s Last Name: MYRA
First Name
JOHNSON
DOB___________
Parent/Caregiver’s Name:_______________________________________________________________________________
Qualifying Condition/Diagnosis/ICD-9code: __________________________________________________________________
Allergy, confirmed [Cow’s milk protein, soy] (693.1) 353 Autoimmune Disorder (279.4) 352
Cerebral Palsy (343.9) 348
Cystic Fibrosis (277.00) 360
Congenital Anomaly, Respiratory (748.9) 360 Congenital Heart Disease (746.9) 360
Developmental Sensory/Motor Delays (783.40) 362
Failure to Thrive (C-783.41, W-786.7) 134 Gastroesophageal Reflux (580.81) 342
Immunodeficiency (279.3) 352
Inadequate growth(783.40) 135
Intestinal Malabsorption (579.9) 342
Lactose or Sucrose Intolerance (271.3) 355
Low Birth Weight(765.10) 141
Low Maternal Wt Gain (646.83) 131
Metabolic Disorders (277.9) 351
Neuromuscular Disorder (358.9) 349
Prematurity (765.10) 142
Pyloric Stenosis (537) 342
Seizure disorder requiring ketogenic diet (345.90) 348
Underweight (783.22) Women- 101, Inf/C-103
Cancer: type: __________ ICD-9 code: ________ 347
Other medical condition: ________________________ICD-9 code: __________360
***NOT ALLOWED: constipation, diarrhea, unconfirmed allergies, or for managing body weight, lactose intolerance symptoms, or growth
concerns unless there is an underlying medical condition.
Measurements:
Date: _____________ Length/Height __________Weight __________ If premature: Birth Weight ________Weeks Gestation_____
B. Name of Formula(s):____________________________________________________________________
Requested length of issuance:
3 months
6months
Formula amount: __________ per day*
*Maximum allowed by federal guidelines (6 months) will be provided unless otherwise indicated
Infants (6-12 months old)
Full provision of formula and infant foods will be issued unless checked below
Provide only formula past 6 months of age due to inability or delay in consuming solids
Infants unable to eat and on therapeutic (non-standard) formula may be eligible for an increased amount of formula.
Check WIC Supplemental Food to OMIT at 6 months of age
Infant Cereal
Baby Food
(Fruit &/or Vegetables)
Children (1-5 years old) and Women
All appropriate WIC foods, except milk, will be issued
with prescribed formula unless checked below
Provide whole milk in addition to formula
For milk allergy, formula or Goat milk___________________
Provide infant foods for cash value fruits/vegetables
No supplemental foods. Provide formula only
Check WIC Supplemental Foods to OMIT from Food Package
P-nut
Cheese
Butter
Cereal
Juice
Whole
Fruits/
Eggs
Beans
Grains
Veg.
C.Required Health Care Provider Information
Signature/stamp of Health Care Provider (MD, DO, PA,NP):___________________________________Date:_____________________________________________
Provider’s Name (Please Print) ____________________________________________________________________________________________________________
Phone No: _______________________________________ Fax No: _____________________________________________________________________________
Provider allows WIC Nutritionist or RD to select and advise client on appropriate foods______________________________________________________________
Federal regulations require all WIC programs to obtain a formula rebate contract for cost containment. NM WIC contracts with Nestles, Gerber formulas.
New Mexico Medical Request for Formula/Food
Directions:
For ALL PATIENTS: Complete Sections A
For MEDICAL FORMULA AND FOOD: Complete Section B
For HEALTH CARE PROVIDER SIGNATURE: Complete Section C
Please return this form to participant’s WIC clinic. (FAX is acceptable)
The following formulas are available from NM WIC (Women, Infants & Children)
Star Medical Issued Formula
Standard e-WIC Card Issued Formulas
NO RX Needed
(Infants & Children)
(Women, Infants & Children)
for Infants under
12 mo
Boost Kid Essentials 1.0 8oz (children)
Alimentum powder 16oz 22 cal/per/oz (infants/children)
Boost Kid Essentials 1.5 8oz (children)
Alimentum RTF 32oz (infants/children)
Boost Kid Essentials 1.5 w/fiber 8oz (children)
Boost Kid Essentials 8.25oz – van/choc (children)
Bright Beginnings Soy RTF 8 oz (children)
Boost Plus RTF 8oz (women and children)
Elecare DHA/ARA 14.1 oz powder (infants/child)
Enfacare powder 12.8oz 22 cal/per/oz (infants/children)
Elecare Jr. Vanilla/plain powder 14.1oz
Ensure RTF 8oz (women)
(children)
Enfacare RTF 32oz 22 cal/per/oz
Gerber GS Gentle powder 12.7 oz (infant/child)
X
(infants/children)
Enfamil Enfaport RTF 6 oz (infants)
Gerber GS Gentle Conc. 12.1 oz (infant/child)
Enfamil Premature 24 cal 2 oz RTF
Gerber GS Gentle RTF 8.45 oz 4pk( infant/child)
(infants/child)
Enfamil Premature Hi Pro 24 cal 2oz RTF
Gerber Good Start Gentle for supplementing 12.4 oz
(infants)
(inf/child)
Gerber GS Premature 24 cal RTF 3oz (infants)
Gerber Good Start Soothe powder 12.4 oz (inf/child)
Hominex 1 powder 14.1oz (infants/children)
Gerber Good Start Soy powder 12.9 oz (infant/child)
Hominex 2 powder 14.1 oz(Children)
Gerber Good Start Soy Concentrate 12.1 oz (infant/child)
Ketocal 4:1 RTF (children)
Gerber Good Start Soy RTF 8.45 oz 4 pk (infant/child)
Monogen powder 14.3oz (infants)
Neosure Expert Care pwd 13.1 oz 22 cal (infant/child)
Neocate DHA/ARA powder 14.1oz (infant/child)
Nutramigen Enflora pwd 12.6 oz
Neocate Jr powder 14oz (trop frt,choc,strawbry)
Pediasure RTF 8 oz multiple flavors 6 pk(child)
Neocate Jr. w/prebiotics 14oz Plain/Van (child)
Pediasure w/fiber RTF 8 oz vanilla(child)
Neosure RTF 32 oz 22 cal/per/oz (infants)
Gerber Graduates Gentle Toddler pwd 22 oz (children)
Nutramigen con. 13 oz (infants/children)
Gerber Graduates Protect pwd 22 oz (children)
Nutramigen RTF 32 oz (infants/children)
Gerber Graduates Soy pwd 24 oz (children)
Nutramigen Enflora LGG 12.6oz powder
Nutren Jr. 8.45 oz , Nutren Jr. 8.45 oz w/fiber
Pediasure 1.5 RTF 8oz (children)
Pediasure 1.5w/fiber RTF 8oz (children)
Pediasure w/fiber ScFos Enteral 8oz RTF (child)
Pediasure Peptide 1.5 8oz RTF (children)
Neocate Splash 8oz RTF (children)
Peptamen Jr. 1.0 RTF
8.45oz Tetra pk (children)
Peptamen Jr. 1.5 RTF
Periflex powder 14 oz
Phenex-1 powder 14.1 oz
Phenex-2 powder 14.1 oz
Portagen powder 16 oz (infant/children)
Pregestimil 16oz powder (infant/children)
PurAmino powder 14.1oz (infants/children)
Similac PM 60/40 powder (infant/children)
Visit: www.nmwic.org for additional information.
Rev. 2/2/2015
Similac Special Care 30cal 2oz RTF (infant)
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 Ave. 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.
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