Arizona Women, Infants & Children (WIC)

Medical Documentation Requirements

The United States Department of Agriculture requires the need for detailed medical documentation for specialty formula, milk alternatives, and formula for premature and medically fragile infants. To help meet the needs of Arizona Physicians’ and to be in compliance with the USDA, Arizona WIC has made these three forms available to download.

Please contact Adrienne Udarbe at udarbea@azdhs.gov or Jesse Lewis at lewisja@azdhs.gov with any questions or concerns.

• Arizona WIC Special Formula Authorization Form for Children, Women, and Healthy Infants
• Arizona WIC Special Formula Authorization Form for Premature and Medically Fragile Infants
• Arizona WIC Milk Alternative Request Form

Medical documentation is now required in the following situations:

• Any infants receiving non-contract/exempt or specialty infant formula or WIC eligible medical food and amount
• For those participants receiving formula or medical foods, allowable supplemental foods to be provided in addition to the formula including amount
• Children receiving milk substitutions of soy beverage, tofu, or goat’s milk
• Requests for children to receive additional cheese that exceeds the maximum substitution rate
• Requests for women to receive additional tofu and cheese that exceeds the maximum substitution rate

Medical documentation form requirements:

• Name of authorized WIC formula (infant formula, exempt formula, WIC-eligible medical food) prescribed, including amount needed per day
• Qualifying condition(s) for issuance of WIC formula prescribed and/or supplemental food authorized for the participant
• Length of time the prescribed WIC formula and/or supplemental food is required by the participant
• Signature, date and contact information (or name, date and contact information if initial documentation was received by phone) of the requesting health care provider
• Name of authorized supplemental food(s) appropriate for the qualifying condition(s) and their prescribed amounts

What if my patient is a participant of both AHCCCS and WIC? 

If your patient has AHCCCS healthcare coverage and is an EPSDT member who is also a WIC client, WIC is a secondary provider of specialty exempt formulas.  Please submit the 430-3 Form "ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM CERTIFICATE OF MEDICAL NECESSITY FOR COMMERCIAL ORAL NUTRITIONAL SUPPLEMENTS" directly to the healthcare plan for coverage of specialty exempt formulas.

What does WIC have to do with me as a healthcare provider/clinician?

• WIC can give patients nutrition counseling and free nutritious foods at critical periods of growth and development.
• WIC counts on clinicians to provide medical information on women and children at risk and to help eligible people know about WIC services.
• Please refer your patients to WIC! WIC wants to serve every eligible person.

WIC appreciates the support received from clinicians and is always open to ways to improve collaboration with you!

How can I help my patients receive WIC benefits?

• Make it routine! Put a WIC brochure in every new-patient packet.
• Mention WIC to everyone. Tell your patients that WIC is a health and nutrition program and encourage them to call a local WIC program or 1-800-2525-WIC.
• Give your patients a complete Medical Referral Form. This helps WIC identify the medical or nutritional risk factor(s) needed for enrollment.
• Display WIC posters and brochures in your office in the languages your patients speak.

Why does the Arizona WIC Program encourage the use of certain infant formula?

Arizona WIC entered into an agreement with Abbott Laboratories (Ross Products Division) to provide Similac Advance with Iron, Similac Isomil Advance Soy and Similac Sensitive as the sole source milk-based and soy-based formulas for WIC participants.

The agreement is a federally mandated cost containment system. It provides a savings to the Arizona WIC Program. This savings allows the Arizona WIC Program to serve additional caseload with the WIC grant.

In accordance with federal regulations, WIC-eligible formulas are mainly issued in powdered forms. The issuance of a ready-to-feed formula is limited to exceptions when there is an unsanitary or restricted water supply, there is poor refrigeration, the infant caretaker may have difficulty in correctly diluting a concentrated liquid or powdered product, or the product is available in only a ready-to-feed form. All other standard milk-based or soy-based infant formulas require a prescription from a prescriptive authority.

How can a special formula be prescribed for a WIC participant?

A WIC participant who is prescribed any formula other than Similac Advance with Iron, Similac Isomil Advance Soy or Similac Sensitive must have a completed prescription.  It must include the participant's name, diagnosis, formula prescribed, and original signature/date. The form may either be returned to the participant to give to WIC staff or faxed directly to the WIC clinic.

Why does the Arizona WIC Program not allow cow's milk for WIC participants until one year of age?

The Arizona WIC Program does not allow cow's milk before the age of one. The Committee on Nutrition of the American Academy of Pediatrics (AAP) recommends the consumption of breast milk or iron-fortified infant formula, along with age-appropriate solid foods and juices, during the first twelve months of life. The AAP recommends that whole cow's milk and low-iron formulas not be used during the first year of life (AAP, The Use of Whole Cow's Milk in Infancy, Pediatrics, 1992, 89:1105-1109).

Why does the Arizona WIC Program not encourage reduced fat milk for WIC participants until two years of age?

The Arizona WIC Program recommends for children age 12 to 23 months whole milk for the type of milk used in the WIC food package. Per recommendations of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents (National Cholesterol Education Program/NIH), The American Academy of Pediatrics Committee on Nutrition, and The American Heart Association Nutrition Committee, fat and cholesterol should not be restricted during the first two years of life (AAP, Pediatric Nutrition Handbook, 1993, page 44; NIH, Report of the Expert panel on Blood Cholesterol Levels in Children and Adolescents, 1991, page 1).

Please visit our food package page for more information on the exciting changes to the WIC food packages.

Additional information for healthcare providers/clinicians:

• IOM’s 2009 report, "Weight Gain During Pregnancy: Reexamining the Guidelines"
• Dietary recommendations for children and adolescents
• AAP policy on breastfeeding
• Formula Changes and Updates May 2010:
  • Letter from Enfamil on PREMIUM Name Change
  • Image of New Enfamil Label
• Updated Information on Bisphenol-A (BPA)
• AZ WIC Formulary – FFY2010