WIC Information for Healthcare Providers

Essential WIC forms and resources for health care providers.

Medical Formula

Forms

• Request for Medical Formula for Infants 972e
• Request for Medical Formula for Women and Children 263e

Documents

• List of WIC-Approved Medical Formulas PDF
• Formulary: Medical Formula Amounts Guide PDF

Refer to the formula manufacturer for details regarding specific formulas.

Medicaid

• Medicaid Prior Authorization Form PDF