Dear Health Care Provider
Name of Infant/Child: Name of Parents: DOB This child is enrolled in the Wisconsin WIC Supplemental Food Program. The Wisconsin WIC program is not able to provide the infant formula or enteral product that you or your patient requested because: Wisconsin WIC does not provide the requested infant formula.
Wisconsin WIC provides this product at a maximum quantity of ounces/ day to a infant/child this age. This infant/child requires more each day than WIC is able to provide. Child requires milk/cheese, eggs or peanut butter or dry beans from WIC. Due to federal regulations WIC is therefore unable to also provide medical food..
This child may be eligible for infant formula or enteral products through the Medicaid program. The Medicaid program covers medically necessary nutritional supplements that are used for the treatment of severe health conditions to Medicaid eligible infants and children. The request for a Pediatric enteral product begins with a physicians order. The pharmacist finalizes the prior authorization with the clinical information he or she is provided. The form and instructions for completion are available at: http://dhfs.wisconsin.gov/forms/DHCF/HCF11054.pdf You will note that the following information is required by the Medicaid program on the prior authorization form: Clinical justification of medical necessity for requested product. Why was this particular medical nutritional chosen? (Section IV, no.14) Height and weight and growth percentiles- height/age and weight/age (Section V, no.18) Amount of weight loss (include time frame and change in growth percentile or weight gain or maintenance compared to expected weight gain for age. (Section V, no. 20) Note any history of diarrhea (amount, frequency), malabsorption (degree of malabsorption), GI problems interfering with intake If not tube fed, the number of kilocalories required per day and the percent of total calories obtained from the supplement (Section V, no. 21) Whether recipient has a clinical condition that prevents the consumption of normal table, softened, mashed, pureed or blended food. (Section V, no. 21)If child is unable to swallow, include documentation of swallow studies. Include all other lab values or physical findings to document the severity of the condition.
Whether the participant can receive the product from WIC. (WIC participants should document rationale for requesting product from Medicaid.) Specific quantity (ccs for a liquid product, gms for a powder) to be taken as a daily dose and the number of calories contained in the amount of product prescribed. (daily dose{in cans}*days supply)*units per can=total units
Anthropometric measurements obtained at WIC: Most current Date Length or Height Weight Length or Height /age % weight/ length % or BMI%
Infant/child falls below weight range for age Infant/child fails to gain at expected growth rate
Prior anthropometric measurements obtained at WIC-if available Date Length or Height Weight Length or Height /age % weight/ length % or BMI%
WIC Program Information:
Please contact WIC nutritionist with any questions concerning the WIC program.
In accordance with Federal Law and US 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 Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 or (202) 7206382 (TTY). USDA is an equal opportunity provider and employer.