About WIC Prescriptions
Federal regulations require WIC to obtain medical documentation from a health care provider when a participant needs a therapeutic formula or medical food. We have developed the WIC Medical Documentation Form to make it easier for health care providers to communicate the required information to WIC staff.
Other forms of medical documentation are acceptable if they include ALL of the information listed below.
What information is needed?
When a client needs a therapeutic formula or medical food, WIC requires complete medical documentation that includes the:
- Name of the therapeutic formula or medical food.
- Amount of the therapeutic formula or medical food.
- Qualifying medical diagnosis.
- Amount of time the prescription is valid (up to a maximum of six months).
- Contact information for the health care provider.
- Signature of the health care provider with prescriptive authority.
- Date of the prescription.
WIC Medical Documentation Forms
- Women (PDF)
- Infants (PDF)
- Children (PDF)
- Medical Documentation Form (Fillable PDF) – NEW! (Effective June 30, 2025)
Qualifying Conditions
Qualifying conditions include, but aren't limited to premature birth, low birth weight, failure to thrive, inborn errors of metabolism and metabolic disorders, gastrointestinal disorders, malabsorption syndromes, immune system disorders, disease and medical conditions that impair ingestion, digestion, absorption or the utilization of nutrients.
Supplemental Foods
View a complete list of Washington State WIC Nutrition Program's foods.