An exempt formula may be provided for specific medical diagnoses. This means WIC state agencies agree to provide one brand of infant formula and in return the manufacturer gives the state agency a rebate for each can of infant formula purchased by WIC participants. WIC STAFF USE ONLY WIC staff must complete section in its entirety and note commentsactions Consent on file at WIC Medical Documentation for WIC Formula and Approved WIC Foods for Women Infants and Children DOH-4456 515 Page 1 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Division of Nutrition.
WIC can also provide women infants and children with specialexempt formulas such as hypoallergenic hypercaloric elemental and metabolic formulas with an appropriate nutrition related ICD-10 code medical diagnosis.
WIC announces new formula contract for 2021. This means WIC state agencies agree to provide one brand of infant formula and in return the manufacturer gives the state agency a rebate for each can of infant formula purchased by WIC participants. Please contact the Local WIC clinic see back of form or the State WIC Office at 1-800-242-4942 with any questions about any products that are WIC-eligible. Patient Information required Formula Requested required For intolerance to Similac Advance or Similac Isomil choose one alternate 19 calorie WIC formula below.