How can a special formula be prescribed for a West Virginia WIC participant?
A WIC participant who is prescribed formula other than Similac Advance Early Shield, Similac Sensitive, Similac Sensitive RS, or Isomil must have a completed WV WIC Prescription Formula Documentation Form (WIC-53) prior to issuance of drafts for the special formula. The form may be obtained from the local WIC clinic. The form must be completed by a physician or health care provider with prescriptive authority. It must include the participant’s name, diagnosis, formula prescribed, and original signature/date. A signature stamp will not be accepted. The form may either be returned to the participant to give to WIC staff, or mailed directly to the WIC clinic. The form may be faxed to the WIC clinic, with the original sent by mail, when the participant must receive issuance of drafts for the formula quickly. Any special formula can be issued in either concentrate or powder form, provided it is manufactured in that form. The issuance of a ready-to-feed formula is limited to exceptions when
