WIC health partners should fill out the Medical Request for Formula form to request WIC formulas for their patients. Once completed, fax the form to your patient’s local WIC clinic, or print it for the patient to bring to the clinic.  

Local WIC clinical staff have to review all medical requests for formula, which are subject to approval based on WIC state agency policy and federal regulations.

Please carefully review the instructions and forms before completing them. Health partners are encouraged to call their local WIC clinic or state agency WIC staff if they have any questions about the formula prescription process or forms. 

Visit Infant Feeding Options for more information about WIC formulas and the criteria for their use in the WIC program.