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Fill Out a Valid Virginia Wic 395 Template

The Virginia WIC 395 form is a critical document aimed at ensuring infants, children, and women under the care of the Women, Infants, and Children (WIC) Program in Virginia receive the necessary special food prescriptions due to medical conditions or dietary needs. It outlines the process for healthcare professionals to request special formulas, nutritionals, and modified food benefits for their patients within the WIC program. If you're a healthcare professional with patients who may benefit from this program, click the button below to learn more about filling out the form accurately.

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Fill Out a Valid Virginia Wic 395 Template

Structure

The Virginia WIC 395 form is a crucial document designed to address the nutritional needs of infants, children, and women under the Women, Infants, and Children (WIC) Program in Virginia. This form serves as a request for special food prescriptions, accommodating those who cannot consume the standard formula offerings due to medical conditions. The Virginia Department of Health emphasizes breastfeeding but recognizes the need for alternative formulas such as Similac Advance and Similac Soy Isomil, provided under a contract with Abbott Nutrition. However, for participants with different dietary needs, the WIC 395 form allows healthcare professionals to prescribe specialized formula, nutritionals, or modified food benefits. This ensures that every participant receives the appropriate nourishment, respecting the program's limitations on direct formula supply from manufacturers other than Abbott Nutrition. It further details the process for requesting formula modifications and specifies the documentation needed for infants manifesting intolerance to the standard WIC formula offerings. Importantly, this form underlines the conjunction of healthcare assessments with WIC policy to continually support the beneficiaries' dietary requirements, demonstrating a structured approach to managing nutritional health within the program's framework.

Virginia Wic 395 Example

Virginia WIC Request for Special Prescription

WIC-395 Form

Requests are subject to approval based on Virginia WIC policy.

Additional information located at www.vdh.virginia.gov/wic/healthcare-providers

Full completion of Sections A – E required at submission

INFANT FORM

A. Patient Information

Infant Name:

DOB:

Guardian Name:

Phone: ( )

B. Anthropometric Data

Provide most recent data collected on the same date.

Both values are required.

Weight: lbs. oz. Length: in.

Collection Date:

C.Formula Information Please include ALL products requested for patient on single form

Product(s) requested:

Is RTF medically required?:

☐ No

☐ Yes

If yes, provide RTF justification:

Amount per day: ☐ Standard WIC amount or

oz/day

Calories per ounce: ☐ Standard dilution

kcal/oz

Length of use: ☐ 1 month

☐ 2 months

☐ 3 months

☐ 4 months

☐ 5 months

☐ 6 months

Diagnosis with ICD code:

All Failure to Thrive diagnoses must be supported by a current weight that is < 3rd percentile for age, current weight < 80% of ideal weight for height/age, or documented decrease in growth along infant’s previously defined growth curve.

WIC is a supplemental program and the formula and food benefits provided are not intended to meet the full nutritional needs of participants. Formula amounts over the standard WIC amounts are only available for infants who have qualifying Virginia Medicaid coverage and a qualifying diagnosis.

Contract WIC formulas (Similac Advance, Soy Isomil, Sensitive, Total Comfort, and Spit-up) cannot be issued in amounts over the standard WIC amount and RTF forms of these products cannot be issued for reasons related to tolerance.

D.Allowable WIC Foods Selection of at least 1 option is REQUIRED

Beginning at 6 months of age, WIC provides supplemental foods to infants in addition to prescribed formula. Please indicate any restrictions required for the duration of this prescription-

☐No restrictions or infant is under 6 months of age for duration of prescription

☐ Delay WIC foods until		☐	Remove Infant Cereal
	months of age	☐	Remove Infant Pureed Fruits/Vegetables
		☐	Remove Infant Pureed Fruits/Vegetables

E. Health Care Provider Information

Printed Name:

☐ MD ☐ DO ☐ PA ☐ ARNP

Address:

Phone:

Fax:

Signature of healthcare provider authorized to	Date
write medical prescription under state law

WIC STAFF USE ONLY

Family ID:	Issuance Day:

Approved: ☐ Yes ☐ No	If no, provide details below :

Medicaid: ☐Yes ☐No	OTM: ☐Yes ☐No If yes, provide calculations:

Printed Name:

☐ RD ☐ CPA ☐ CPPA

Staff Signature

Date

This institution is an equal opportunity provider.	WIC-395 6/21

Virginia WIC Request for Special Prescription

WIC-395 Form

Requests are subject to approval based on Virginia WIC policy.

Additional information located at www.vdh.virginia.gov/wic/healthcare-providers

Full completion of Sections A – E required at submission

CHILD FORM

A. Patient Information

Child Name:

DOB:

Guardian Name:

Phone: (

)

B. Anthropometric Data

Provide most recent data collected on the same date.

Both values are required.

Weight:

lbs.

oz. Height:

in.

Collection Date:

C.Formula Information Please include ALL products requested for patient on single form

Product(s) requested:

Is RTF medically required?:

☐ No ☐ Yes

If yes, provide RTF justification:

Amount per day:

oz/day

Calories per ounce:

☐ Standard dilution or

kcal/oz

Length of use:

☐ 1 month

☐ 2 months

☐ 3 months

☐ 4 months

☐ 5 months

☐ 6 months

Diagnosis with ICD code:

The following are considered non-qualifying conditions and will not be approved- colic, constipation, diarrhea, gas, fussiness, weight loss, slow or poor weight gain, non-specific feeding difficulties, spitting-up, vomiting, non-specific formula intolerances or allergies, picky eating, enhancing nutrient intake or managing body weight without a documented underlying medical condition, food intolerances or allergies that can be managed with regular foods, or preference.

WIC is a supplemental program and the formula and food benefits provided are not intended to meet the full nutritional needs of participants. Formula amounts over the standard WIC amounts are only available for children who have qualifying Virginia Medicaid coverage and a qualifying diagnosis.

D.Allowable Foods Selection of at least 1 option is REQUIRED

☐ No restrictions, issue all WIC foods in addition to formula

☐ Provide formula only, remove ALL other WIC foods

☐Remove the following WIC foods:

☐ Milk/Yogurt/Cheese	☐ 100% Juice	☐ Cereal	☐ Beans/Legumes
☐ Whole Grains	☐ Eggs	☐ Fruits/Vegetables	☐ Peanut Butter

☐Provide the following modifications in addition to the requested formula:

☐ Substitute pureed fruits/vegetables	☐ Substitute whole milk for 1% and
for regular fruits/vegetables	skim milk (age 2 and older, only)

☐Substitute 2% milk for 1% and skim milk (age 2 and older, only)

E. Health Care Provider Information

Printed Name:

☐ MD ☐ DO ☐ PA ☐ ARNP

Address:

Phone:

Fax:

Signature of healthcare provider authorized to	Date
write medical prescription under state law

WIC STAFF USE ONLY

Family ID:	Issuance Day:

Approved: ☐ Yes ☐ No	If no, provide details below :

Medicaid: ☐Yes ☐No	OTM: ☐Yes ☐No If yes, provide calculations:

Printed Name:
	☐ RD ☐ CPA ☐ CPPA


Staff Signature	Date

This institution is an equal opportunity provider.	WIC-395 6/21

Virginia WIC Request for Special Prescription

WIC-395 Form

Requests are subject to approval based on Virginia WIC policy.

Additional information located at www.vdh.virginia.gov/wic/healthcare-providers

Full completion of Sections A – E required at submission

WOMAN FORM

A. Patient Information

Name:

DOB:

Phone: (

)

B. Anthropometric/Clinical Data

Weight: lbs. oz. Height: in.

Collection date:

EDD or pregnancy end date:

C.Formula Information Please include ALL products requested for patient on single form

Product(s) requested:

Amount per day:

oz/day

Calories per ounce:

☐ Standard dilution

kcal/oz

Length of use:

☐ 1 month

☐ 2 months

☐ 3 months

☐ 4 months

☐ 5 months

☐ 6 months

Diagnosis, please select ALL that apply:

☐

Low maternal weight gain / maternal weight loss, O26.1 pregnant women only

☐

Hyperemesis Gravidarum, O21.0

pregnant women only

☐

Current or pre-pregnancy BMI < 18.5, R63.6

pregnant and breastfeeding women only

☐Severe allergies, MUST specify and include ICD:

☐Other, MUST specify and include ICD:

D. Allowable Foods Selection of at least 1 option is REQUIRED

☐ No restrictions, issue all WIC foods in addition to formula

☐ Provide formula only, remove ALL other WIC foods

☐Remove the following WIC foods:

☐ Milk/Yogurt/Cheese	☐ 100% Juice	☐ Cereal	☐ Beans/Legumes
☐ Whole Grains	☐ Eggs	☐ Fruits/Vegetables	☐ Peanut Butter

☐Canned Fish (women who are pregnant with multiples or fully breastfeeding only)

☐Provide the following modifications in addition to the requested formula:

☐ Substitute pureed fruits/vegetables	☐ Substitute whole milk for
for regular fruits/vegetables	1% and skim milk

☐Substitute 2% milk for 1% and skim milk

E. Health Care Provider Information

Printed Name:

☐ MD ☐ DO ☐ PA ☐ ARNP

Address:

Phone:

Fax:

Signature of healthcare provider authorized to	Date
Signature of healthcare provider authorized to
write medical prescription under state law

WIC STAFF USE ONLY

Family ID:	Issuance Day:

Approved: ☐ Yes ☐ No	If no, provide details below:

Printed Name:
	☐ RD ☐ CPA ☐ CPPA

Staff Signature

Date

This institution is an equal opportunity provider.	WIC-395 6/21

Download Virginia Wic 395 File

Form Properties

Fact	Detail
Purpose	The form is used to request special food prescriptions for participants in the Virginia Women, Infants, and Children (WIC) Program.
Optimal Feeding	Virginia WIC promotes breastfeeding as the optimal method for feeding infants.
Formula Contract	The program has a contract with Abbott Nutrition to provide Similac Advance and Similac Soy Isomil at a special price.
Formula Restrictions	Due to the contract, Virginia WIC cannot provide standard infant formulas from other manufacturers.
Special Conditions	For medical conditions requiring special formulas, a WIC-395 request form must be completed.
Formulary Link	The current Virginia WIC Formulary of approved formulas/nutritionals is provided online.
Renewal Requirement	A new WIC-395 request form is needed at each subsequent WIC certification appointment or at the end of the indicated duration.
Governing Law	This form operates under the policies and procedures set by the Commonwealth of Virginia Department of Health.
Contact Information	For more information or assistance, contact the State WIC Office or the local office as indicated on the form.

Steps to Filling Out Virginia Wic 395

When a healthcare professional is caring for a Virginia WIC participant who needs special food prescriptions due to medical conditions, they will need to complete the WIC-395 Request for Special Food Prescription form. This form enables the participant to access specific formulas, nutritive products, and modified food benefits that are not typically offered through the standard WIC package. It’s essential to fill out this form accurately to ensure the participant receives the correct food prescriptions. Below are step-by-step instructions for completing the Virginia WIC 395 form.

Start by entering the Patient Information:
- Write the participant's name.
- Fill in the participant's date of birth.
- Provide the parent or caregiver’s first and last name.
Under Current Anthropometric Data, record the following:
- The participant's weight.
- Their length or height.
- Hgb/Hct levels.
- Date these measurements were assessed.
In section C, Alternative Routine Infant Formulas, check the appropriate box for any alternative formulas needed because of intolerance to Similac Advance and/or Similac Soy Isomil. RTF product selections require additional justification.
If an exempt infant formula or nutritional is required, complete section D:
- Enter the product name.
- Select the form (Powder, Concentrate, RTF - with RTF requiring additional justification).
- Diagnosis with ICD code (ensuring symptoms do not include generalized conditions like colic without a specific underlying diagnosed condition).
- Specify calories per ounce and the ounces per day required, if different from standard WIC amounts.
In the WIC Supplemental Foods section, indicate whether to issue full provision of age-appropriate foods, no supplemental foods, or specify any modifications to the standard food package for infants, children, and women.
For Length of Use, indicate the duration of certification (up to 1 year) or specify a different number of months.
Finally, enter the Health Care Provider’s Information at the bottom of the form:
- Type or stamp the provider's name, address, and contact information.
- Sign and date the form to validate the request.

After submission, the Virginia WIC program will review the form to approve and provide the special food prescription based on their policies and procedures. It is crucial for healthcare professionals to fill out this form accurately to ensure that WIC participants receive the specialized nutritional support they need.

FAQ

What is the purpose of the Virginia WIC 395 form?

The Virginia WIC 395 form is used by healthcare professionals to request special food prescriptions for participants of the Virginia Women, Infants, and Children (WIC) Program. This includes special formulas, nutritionals, and/or modified food benefits for infants, children, and women with medical conditions that require them. The form enables participants to receive appropriate supplemental foods alongside their WIC benefits.

Which infant formulas are standardly provided by the Virginia WIC program?

The Virginia WIC program primarily offers Similac Advance and Similac Soy Isomil formulas due to a special pricing contract with Abbott Nutrition. These options are promoted as part of the program's efforts to encourage breastfeeding but provide formula options for those who need them.

Can Virginia WIC provide formulas from manufacturers other than Abbott Nutrition?

No, due to the contract with Abbott Nutrition, Virginia WIC cannot provide standard infant formulas made by other manufacturers such as Mead Johnson (Enfamil), Nestle (Gerber Good Start), or generic/store brands.

What if a Virginia WIC participant requires an alternative or special formula?

If a Virginia WIC participant requires an alternative due to lactose sensitivity, digestive issues, or another medical condition, healthcare professionals can request alternative formulas or nutritionals by completing the WIC-395 form. This includes options like Similac Sensitive and Total Comfort powders. For exempt infant formulas or special nutritionals that are not standardly provided, the form allows for specification of product name, form, diagnosis, and required calorie concentration.

How often does the WIC-395 request form need to be renewed?

A new WIC-395 form is required at each subsequent WIC certification appointment or at the end of the specified duration of the special food prescription, whichever comes first. Additionally, a new form must be submitted for any requested changes to the food prescription.

Can WIC supplemental foods be modified based on a participant's medical needs?

Yes, the WIC-395 form provides options to modify the issuance of WIC supplemental foods based on the medical needs of the participant. These modifications can include providing formula only, omitting certain food groups like infant cereal or fruits and vegetables, and adjusting supplemental foods for children and women.

Who is authorized to complete and submit the WIC-395 form?

The WIC-395 form must be completed and signed by a healthcare professional who is authorized under state law to write medical prescriptions. This ensures that all requests for special food prescriptions are based on medical needs and adhere to Virginia WIC policies and procedures.

Common mistakes

Not providing the participant's full name and date of birth under the patient information section, which is crucial for identifying the individual in the WIC system.
Omitting the current anthropometric data like weight, length/height, and Hgb/Hct levels along with the date assessed, which helps in determining the nutritional requirements of the participant.
Failure to select an alternative routine infant formula from the options provided for those with intolerance to Similac Advance and/or Similac Soy Isomil, thereby missing the opportunity to specify a suitable alternative.
Skipping the section on exempt infant formulas or nutritionals by not listing a product name and form, necessary for participants who need a special formula not covered by the regular contract.
Leaving out the diagnosis and ICD code when a special formula is required due to a medical condition, which is mandatory to justify the need for an exemption.
Not specifying the calories per ounce and the required ounces per day for the exempt formula, details that are essential for tailoring the nutritional provision to the participant's needs.
Overlooking the WIC supplemental foods section, which determines whether the participant will receive a full provision of age-appropriate foods, no supplemental foods, or a modified food package.
Forgetting to indicate the length of use for the special food prescription, which helps in planning the duration of the modified nutritional support.
Not including the health care provider’s contact information and signature at the end of the form, which is necessary to verify the authenticity of the prescription and for any needed follow-up.

Common mistakes :

Neglecting to check the available options under the "C. Alternative Routine Infant Formulas" and "D. Exempt Infant Formulas/Nutritionals," which leads to incomplete requests.
Incorrectly completing or entirely omitting the "E. WIC Supplemental Foods" section, resulting in an incomplete understanding of the participant’s nutritional needs and preferences.
Submitting the form without the required health care professional's signature and failing to print or stamp the health care provider's information, making the form invalid.

Documents used along the form

When navigating the procedures and requirements of the Virginia Women, Infants, and Children (WIC) Program, several forms and documents complement the WIC 395 form. These auxiliary items play crucial roles in ensuring the comprehensive management of the application process, as well as in meeting the program's detailed eligibility and reporting criteria. The integration of these documents helps streamline processes for health care professionals and participants, fostering an environment of organized information sharing and adherence to program guidelines.

Medical Documentation Form: Utilized to provide detailed medical evidence and diagnosis from a healthcare professional. This form supports the request for special formulas or food prescriptions, verifying medical necessity as per the guidelines outlined by the Virginia WIC program.
Income Eligibility Verification Form: This document is crucial for establishing the financial eligibility of the applicant. It requires detailed income information from all sources within the household, ensuring participants meet the WIC program's income guidelines.
Virginia WIC Program Food List: An essential document for participants and healthcare providers alike, listing the foods approved by the Virginia WIC, ensuring that prescriptions and counseling align with the available food package options.
Participant Rights and Responsibilities Form: A document that outlines the expectations, rights, and responsibilities of the participants within the WIC program, ensuring they are informed and committed to adhering to the program regulations.
Authorization for the Release of Medical Information Form: This form allows WIC staff to request and receive medical records and other health information from healthcare providers. It is used with the WIC 395 form when medical documentation is necessary to support special food or formula prescriptions.
Benefit Issuance Record: Employed to record the issuance of WIC benefits to participants, including special formula prescriptions. It aids in tracking the distribution of benefits and ensures proper allocation as per the participant's eligibility and needs.

These documents facilitate a structured approach towards managing participant eligibility, nutritional and health assessments, and benefit issuance within the Virginia WIC program. By adhering to required processes and documentation, participants and healthcare providers can efficiently navigate the program's offerings, ensuring that essential nutrition and support are accessible to those in need. Therefore, the synchronization of these forms with the WIC 395 form plays a pivotal role in the seamless delivery of services and benefits to the populations served by the Virginia WIC program.

Similar forms

The Virginia WIC 395 form is similar to other specialized healthcare forms that are used across various programs and services to facilitate specific medical needs or dietary restrictions of participants. These forms often serve as a bridge between health care providers and community services, ensuring that individual health considerations are appropriately accommodated within public programs.

One document similar to the Virginia WIC 395 form is the Pediatric Nutrition Prescription Form used in hospital settings. This form allows doctors to specify dietary needs for pediatric patients, including special formulas similar to those discussed in the WIC 395 form. Both documents detail the medical necessity for specific nutritional products, stipulate the required formula or dietary adjustment, and provide a space for healthcare provider approvals. The main difference lies in their use context – while the WIC form is tailored for a community-based program, the Pediatric Nutrition Prescription Form is typically utilized within hospital or clinical environments.

Another closely related document is the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Prescription for Special Dietary Needs found in states outside of Virginia. Though the format and naming might differ slightly, the core purpose aligns with that of the Virginia WIC 395 form. It captures necessary participant information, medical conditions necessitating special formulas or nutritional needs, and the prescribed dietary solution. Both forms facilitate access to specialized nutrition for vulnerable populations, ensuring that infants, children, and women receive appropriate support based on medical recommendations. Such similarities illustrate the concerted effort across states to address public health needs through tailored nutritional support.

The Medicaid Prior Authorization Request Form for Prescription Drugs is another document bearing resemblance to the Virginia WIC 395 form, particularly in its function of requesting special medical provisions. This form is commonly used to gain approval from Medicaid for the coverage of specific prescription drugs not generally covered under the standard plan. Like the WIC form, it requires detailed information about the patient, the medical necessity for the requested item, and formal authorization from a healthcare provider. Both documents play crucial roles in ensuring patients have access to essential, albeit non-standard, medical resources for their health and well-being.

Dos and Don'ts

When filling out the Virginia WIC 395 form, there are specific considerations to keep in mind to ensure the process goes smoothly and effectively. Here's a list of things you should and shouldn't do:

Do carefully read all the provided instructions before filling out the form to avoid misunderstandings.
Do ensure that the participant's name and date of birth are accurately entered in the Patient Information section to prevent any processing delays.
Do accurately record the current anthropometric data, including weight, length/height, and Hgb/Hct values, as this information is crucial for assessing the participant's nutritional needs.
Do select the appropriate formula from the Alternative Routine Infant Formulas if the participant experiences intolerance to the standard WIC formulas.
Do provide a thorough and clear medical diagnosis in the exempt infant formulas/nutritionals section, including the ICD code, to support the need for a special food prescription.
Don't overlook the need to justify the issuance of Ready To Feed (RTF) products, as they require additional justification per WIC policy.
Don't request a formula for the purpose of enhancing nutrient intake or managing body weight without providing a qualifying underlying medical condition.
Don't leave the section on WIC supplemental foods blank. Indicate whether the participant should receive the full provision of age-appropriate foods, no WIC supplemental foods, or modifications to the package.
Don't forget to specify the duration of use for the special food prescription in the Length of Use section, which ensures the participant receives the necessary support for the appropriate amount of time.
Don't submit the form without the signature of a health care professional who is authorized to write medical prescriptions under State law, as this is essential for the form's validity.

By following these dos and don'ts, health care professionals can navigate the process of requesting special food prescriptions through the Virginia WIC program more efficiently, ensuring that participants receive the nutritional support they need in a timely manner.

Misconceptions

There are several common misunderstandings surrounding the Virginia WIC (Women, Infants, and Children) 395 form and its purpose. It’s essential to clear up these misconceptions to ensure that healthcare professionals and WIC participants fully understand how the form is used within the program.

Only specific brands of formula can be provided through WIC. It's true that the form mentions Similac Advance and Similac Soy Isomil due to a contract with Abbott Nutrition. However, the form is also designed to request special formulas or nutritional products when medically necessary. This includes products not typically provided by Virginia WIC, broadening the range of options for participants with unique health needs.
The form limits supplemental food benefits for participants. In reality, participants who receive a special food prescription are still eligible for age and category appropriate supplemental foods. The form ensures participants get the nutritional support they need, including special dietary requirements, without losing access to other benefits.
WIC-395 is a one-time form. A new WIC-395 form must be completed for each subsequent certification appointment or at the end of the indicated duration, whichever comes first. This process ensures that the participant’s needs are regularly evaluated and met.
It's difficult to obtain ready-to-feed (RTF) formulas. While it is mentioned that RTF products require additional justification, this doesn’t mean they are impossible to get. The policy is in place to ensure that RTF formulas are provided when there is a legitimate need, based on specific medical or dietary requirements.
The form is solely for infant formula requests. Although the form places significant focus on infant formulas, it’s also used for requesting special formulas, nutritionals, and food modifications for children and women. This demonstrates the form’s broader purpose in catering to the diverse nutritional requirements of all WIC participants.
Any diagnosis can justify a special formula prescription. The form highlights that symptoms such as colic, constipation, and gas will not be accepted as reasons for special formula provision. Instead, there must be a medical diagnosis that justifies the need for special dietary products, ensuring that resources are allocated to those with medically proven needs.
Formula intolerance is not a valid reason for a special food prescription. While general intolerances may not qualify, intolerances to the primary WIC-provided formulas (Similac Advance and Similac Soy Isomil) due to lactose sensitivity, excessive spit-up, or serious digestive issues can lead to the provision of alternative formulas. The form facilitates these changes to accommodate infants’ differing health conditions.
Supplemental foods cannot be modified. The form allows healthcare providers to request modifications to the supplemental foods provided, tailoring the WIC benefits more closely to the individual needs of participants. This could include omitting certain foods due to allergies or dietary restrictions, for example.

Understanding these key points regarding the Virginia WIC 395 form helps clarify its role within the WIC program, ensuring that participants receive the nutritional support they need in a way that best suits their individual health requirements.

Key takeaways

Understanding the Virginia WIC 395 form is crucial for healthcare professionals who seek to provide the best care for participants in the Women, Infants, and Children (WIC) Program. Here are key takeaways:

The Virginia WIC Program endorses breastfeeding as the ideal nutrition for infants, with Similac Advance and Similac Soy Isomil being the primary formulas offered due to a special pricing contract.
Other standard infant formulas from manufacturers like Mead Johnson (Enfamil), Nestle (Gerber Good Start), or generic/store brands are not provided through the Virginia WIC due to this exclusive contract.
Special food prescriptions, including specialized formulas, nutritionals, or modified food benefits, are available for infants, children, and women under medical necessity. A filled-out WIC-395 form is required to issue these prescriptions.
A new WIC-395 form must be completed at each WIC certification appointment or when any changes to the food prescription are requested, or at the end of the specified duration, whichever is sooner.
Ready To Feed (RTF) formula issuance is subject to additional justification as per WIC policy, and particular criteria must be met for approval.
Diagnoses that lead to symptoms like colic, constipation, spitting-up, gas, or formula intolerance without an underlying medical condition will not qualify for special formula provisions.
WIC supplemental foods are provided alongside age-appropriate formula options unless a medical condition justifies an exemption. Healthcare professionals can request no supplemental foods, provide formula or nutritional only, or modify supplemental food provisions based on the patient's needs.
Healthcare providers must provide detailed information, including diagnosis and ICD codes if applicable, to customize formula and food prescriptions to meet the participant's health requirements.

The collaboration between healthcare professionals and the Virginia WIC program ensures that participants receive the nutritional support they need, while also adhering to program policies and guidelines. By accurately completing the WIC-395 form, healthcare professionals can advocate for their patients' specific health and nutritional needs within the framework of the WIC program.

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