Get Wic Arizona Form

Get Wic Arizona Form

The WIC Arizona Special Formula Authorization Form is designed to help families access specific formulas for infants and children who have unique nutritional needs. Completing this form accurately ensures that clients receive the appropriate formula without delays. To get started, fill out the form by clicking the button below.

Structure

The WIC Arizona Special Formula Authorization Form plays a crucial role in ensuring that eligible women, infants, and children receive the necessary nutritional support they need. This form is specifically designed for healthcare providers to request special formula for clients enrolled in the Women, Infants, and Children (WIC) program. It requires detailed information about the client, including their name, date of birth, and WIC client ID. The form consists of several sections that guide the provider through the process of documenting previous formulas tried, current formula requests, and the amount of formula needed per day. Additionally, it addresses specific diagnoses that may warrant the need for special formulas, such as food allergies or failure to thrive. Providers must also indicate any WIC foods that are inappropriate for the client’s diagnosis and specify the length of time for which the formula is requested. Completing all sections thoroughly is essential to avoid any delays in authorization. The form concludes with spaces for the healthcare provider’s signature and approval from a local nutritionist or state official, ensuring that all requests are properly vetted. For further assistance and additional resources, the Arizona WIC program provides an online portal for healthcare providers.

Wic Arizona Preview

 

 

Arizona WIC Special Formula Authorization Form

 

 

 

Children, Women and Healthy Infants

 

Client Name:

 

 

 

 

 

Date of Birth:

 

WIC Client ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Comments:

 

 

 

(1-5 yr.)

Cheese

 

o

 

 

 

 

 

 

and Women

Eggs

 

o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Peanut butter

 

o

 

 

 

 

 

 

 

 

Whole grains**

 

o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cereal

 

o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Beans

 

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

 

 

To

 

 

 

Comments:

Signature:

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

Revised 2/2014
➤ PDF File

Document Data

Fact Name Details
Form Purpose The Arizona WIC Special Formula Authorization Form is used to request special formula for eligible clients in the WIC program.
Client Information Each form must include the client’s name, date of birth, and WIC Client ID to ensure proper identification.
Sections Requirement All sections of the form, numbered 1 through 7, must be fully completed to prevent delays in formula issuance.
Preferred Formulas WIC encourages the selection of rebated formulas, indicated by an asterisk (*), to maximize benefits.
Diagnosis Requirement A specific medical diagnosis is required for special formula requests, including conditions like prematurity or severe food allergies.
Nutritionist Approval The form must be approved by a healthcare provider and may require local nutritionist approval for issuance.
Formula Types Clients can request various types of formulas, including powder, concentrate, or ready-to-feed options.
Length of Authorization Authorization can be granted until the client’s first birthday or for a specified number of months or weeks.
WIC Foods Restrictions Clients must indicate any WIC foods that are not appropriate for their diagnosis, especially for infants under six months.
Governing Law This form is governed by the Arizona Administrative Code Title 9, Chapter 1, which outlines WIC program regulations.

How to Use Wic Arizona

Filling out the Arizona WIC Special Formula Authorization Form requires careful attention to detail. Completing each section accurately ensures a smooth process for obtaining the necessary formula for your child. Here’s how to fill out the form step by step.

  1. Client Information: Start by entering the client’s full name, date of birth, and WIC client ID at the top of the form.
  2. Formula(s) Previously Tried: List any formulas that have been previously used by the client.
  3. Current Formula Request: Select the WIC contract formula you are requesting. Options include:
    • Similac Advance*
    • Similac Sensitive*
    • Similac for Spit-up*
    • Similac Total Comfort*
    • Enfamil ProSobee*
    • Enfagrow Toddler Transitions Soy*
    • Other (please specify)
    • Alimentum
    • Nutramigen
    • Pediasure (must meet WIC criteria for issuance)
  4. Amount of Formula Requested Per Day: Indicate whether the formula will be given orally or through tube feeding. Specify the form of the formula as well: powder, concentrate, or ready-to-feed.
  5. Diagnosis: Provide the medical diagnosis for routine formula and any special formula or medical food needed. Options include:
    • Formula Intolerance
    • Food allergy
    • Inappropriate growth patterns
    • Prematurity
    • GERD or reflux
    • Dysphagia
    • Failure to thrive
    • Severe food allergy
    • Other (please specify)
  6. WIC Foods: Check any foods listed that are NOT appropriate for the diagnosis. Keep in mind that infants under 6 months will not receive foods.
  7. Length of Time Requested: Indicate the length of time for which the formula is needed: up to the first birthday, number of months, or number of weeks.
  8. Provider Information: Print the healthcare provider’s name and title, sign and date the form, and provide a phone number for follow-up.
  9. Approval Section: The local nutritionist or state approval will indicate whether the request is approved or not, along with the length of authorization and any comments.

After filling out the form, double-check for any missing information or errors. Submitting a complete and accurate form will help facilitate the approval process, ensuring your child receives the necessary nutrition without delay.

Key Facts about Wic Arizona

What is the WIC Arizona Special Formula Authorization Form?

The WIC Arizona Special Formula Authorization Form is a document used to request specific formulas for infants and children who have special dietary needs. This form helps ensure that eligible clients receive the appropriate nutrition based on their medical conditions.

Who needs to fill out this form?

This form must be completed by healthcare providers for WIC clients who require special formulas due to medical diagnoses. It is essential for children and women who may have specific nutritional needs that standard formulas cannot meet.

What information is required on the form?

The form requires detailed information, including the client's name, date of birth, WIC Client ID, and the specific formula requested. Additionally, it asks for the diagnosis, the amount of formula needed, and the length of time for which the formula is requested.

What types of formulas can be requested?

Clients can request WIC contract formulas such as Similac Advance, Similac Sensitive, and Enfamil ProSobee. There are also options for special formulas like Alimentum and Nutramigen, depending on the diagnosed needs of the client.

How can I ensure my request is processed quickly?

To avoid delays, make sure to complete every section of the form thoroughly. Provide accurate information about the formulas previously tried, the current request, and any relevant medical diagnoses.

What if the client is under six months old?

Infants under six months will not receive solid foods. The form allows for the selection of appropriate formulas, and all foods become available once the infant reaches six months of age.

What happens after the form is submitted?

Once the form is submitted, a local nutritionist or state official will review it. They will approve or deny the request based on the provided information and the client's eligibility for WIC services.

What if the request for formula is not approved?

If the request is not approved, the healthcare provider will receive feedback. They may need to provide additional information or consider alternative formulas based on the client's needs.

How long is the authorization valid?

The length of authorization can vary. It may be granted until the client’s first birthday or for a specified number of months or weeks, depending on the individual circumstances and needs.

Where can I find more information about the WIC program?

For additional forms or information about the WIC program in Arizona, visit the official website at http://www.azwic.gov/physicians.htm.

Common mistakes

Filling out the WIC Arizona form can be a straightforward process, but mistakes can lead to delays in receiving assistance. Here are ten common errors to avoid when completing the form.

One of the most frequent mistakes is leaving sections incomplete. Each part of the form is essential for processing your request. If you skip any section, it could slow down the approval process. Make sure to fill out every section from 1 to 7.

Another common error is not specifying the correct formula. The form provides a list of WIC-rebated formulas, marked with an asterisk (*). Choosing a non-rebated formula can lead to complications. Always select from the approved options when possible.

Many people forget to indicate the amount of formula requested per day. This information is crucial for the WIC program to determine your needs. Be sure to specify whether the formula is for oral or tube feeding, and choose the correct form: powder, concentrate, or ready-to-feed.

Failing to provide a clear diagnosis is another mistake. The form requires specific medical reasons for requesting routine or special formulas. Generic terms won’t suffice; be precise and provide the exact diagnosis to avoid delays.

Some applicants overlook the section regarding WIC foods that are inappropriate for the diagnosis. If you check any foods that should not be given, it’s vital to do so accurately. Misunderstanding this section can lead to receiving foods that are not suitable for your child.

Another error involves the length of time requested for formula authorization. Be clear whether you need assistance until the first birthday, a specific number of months, or weeks. This detail helps ensure that you receive the necessary support for the right duration.

Additionally, it’s important to ensure that the healthcare provider’s name and signature are clearly printed and signed. Incomplete or illegible information can cause confusion and delays in processing your application.

Make sure to double-check the phone number of the healthcare provider. If WIC needs to reach out for clarification, an incorrect phone number can lead to further delays in your application.

Lastly, be mindful of the comments section. Providing additional information can help clarify your situation. However, vague comments or leaving this section blank may hinder the review process.

By avoiding these common mistakes, you can help ensure that your WIC Arizona form is processed smoothly and efficiently. Taking the time to fill out each section accurately will lead to quicker assistance for you and your family.

Documents used along the form

When applying for WIC (Women, Infants, and Children) benefits in Arizona, several other forms and documents may accompany the WIC Arizona Special Formula Authorization Form. These documents help ensure that clients receive the appropriate support and resources. Below are some commonly used forms that may be required or beneficial in the process.

  • WIC Application Form: This initial form collects essential information about the applicant, including personal details, household income, and nutritional needs. Completing this form is the first step in the WIC enrollment process.
  • Health Care Provider Referral Form: A healthcare provider may need to fill out this form to verify the applicant's medical conditions or nutritional needs. It serves as a critical link between the medical provider and the WIC program.
  • Nutrition Assessment Form: This document evaluates the nutritional status of the applicant. It may include questions about dietary habits, health history, and growth measurements to tailor the WIC services effectively.
  • Verification of Income Form: This form is used to confirm the household income of the applicant. It may require documentation such as pay stubs, tax returns, or other financial records to ensure eligibility for WIC benefits.

Each of these documents plays a vital role in the WIC application process, ensuring that families receive the necessary support for their nutritional needs. Understanding the purpose of these forms can help streamline the application process and facilitate access to vital resources.

Similar forms

The Arizona WIC Special Formula Authorization Form shares similarities with several other important documents. Each of these forms serves a specific purpose related to nutritional needs and medical authorizations. Here’s a look at four documents that are similar to the WIC Arizona form:

  • WIC Food Package Form: This document outlines the types of food that WIC clients can receive. Like the WIC Arizona form, it requires specific details about the client's dietary needs and preferences. Both forms aim to ensure that clients receive appropriate nutritional support based on their health conditions.
  • Medical Nutrition Therapy Referral: This form is used to refer patients to a nutritionist for specialized dietary guidance. Similar to the WIC Arizona form, it involves a healthcare provider's input regarding the patient's medical condition and dietary requirements. Both documents emphasize the importance of tailored nutrition plans.
  • Infant Formula Prescription: This document is a prescription specifically for infant formulas, often needed for children with special dietary needs. Just like the WIC Arizona form, it requires a healthcare provider's signature and details about the formula type and quantity. Both forms ensure that infants receive the right nutrition for their health.
  • Child Nutrition Program Application: This application is for families seeking assistance with child nutrition programs. It is similar to the WIC Arizona form in that it collects information about the child’s dietary needs and family circumstances. Both documents aim to provide essential nutrition support to vulnerable populations.

Dos and Don'ts

When filling out the WIC Arizona form, attention to detail is crucial. Here are five important dos and don'ts to consider:

  • Do ensure that you complete every section (1-7) of the form. Incomplete forms can lead to delays in processing.
  • Do select WIC rebated formulas whenever possible. These formulas are marked with an asterisk (*) and are preferred for authorization.
  • Do provide a specific medical diagnosis for any special formula requests. This is necessary for approval.
  • Do check the appropriate boxes regarding foods that are not suitable for the client's diagnosis. This helps to ensure the right nutritional support.
  • Do include your healthcare provider's name, title, and signature, along with their contact information, to validate the request.
  • Don't leave any sections blank. Each part of the form is important for a smooth approval process.
  • Don't forget to specify the amount of formula requested per day. Clarity on this helps in meeting the client's needs.
  • Don't use vague terms when describing the current formula request. Be as specific as possible to avoid confusion.
  • Don't overlook the length of time requested for formula authorization. This information is essential for planning.
  • Don't hesitate to reach out for assistance if you have questions about the form. Support is available to help you navigate the process.

By following these guidelines, you can help ensure that the WIC Arizona form is completed accurately and efficiently, ultimately benefiting the clients who rely on this vital program.

Misconceptions

Misconceptions about the WIC Arizona form can lead to confusion and delays in obtaining necessary formulas. Here are five common misconceptions:

  • The WIC Arizona form is only for infants. This is incorrect. While the form primarily addresses infant formula needs, it also accommodates requests for children and women, including those who may require specific nutritional support.
  • Any formula can be requested on the form. This is misleading. The form encourages the selection of WIC-rebated formulas whenever possible. Non-rebated formulas may not be covered unless there is a specific medical need that justifies their use.
  • Completing the form partially is sufficient. This is not true. To avoid delays, every section of the form must be fully completed. Incomplete forms may result in rejection or additional requests for information.
  • All foods listed are appropriate for every client. This is a misconception. The form requires clients to identify foods that are not appropriate based on their specific diagnosis. This ensures that clients receive only the foods that align with their health needs.
  • The length of authorization is fixed. This is inaccurate. The length of time requested for formula can vary. Clients can request authorization up to the first birthday or specify a duration in months or weeks as needed.

Key takeaways

When filling out and using the WIC Arizona form, consider the following key takeaways:

  • Complete All Sections: Fill out every section of the form (1-7) thoroughly to prevent delays in receiving assistance.
  • Choose WIC Rebated Formulas: Opt for formulas marked with an asterisk (*) as they are WIC-approved and can help streamline the process.
  • Specify the Amount: Clearly indicate the amount of formula requested per day, whether for oral or tube feeding.
  • Provide Accurate Diagnoses: Include specific medical diagnoses for both routine and special formulas. This is essential for approval.
  • Indicate Inappropriate Foods: Mark any WIC foods that are not suitable for the client’s diagnosis to ensure proper nutrition.
  • Length of Time: Specify the duration for which the formula is needed, either until the first birthday or for a set number of months or weeks.
  • Healthcare Provider's Information: Ensure that the provider’s name, signature, and contact details are included for validation and follow-up.

These steps will help ensure that the application process is smooth and efficient.