The Virginia WIC 395 form is a request document used by healthcare professionals to prescribe special food items for participants in the Virginia Women, Infants, and Children (WIC) Program. This form is essential for infants who may require specialized formulas due to medical conditions, ensuring they receive appropriate nutrition. Completing the WIC 395 form allows participants to access necessary food prescriptions while maintaining eligibility for standard WIC benefits.
The Virginia WIC 395 form is a crucial document used by healthcare professionals to request special food prescriptions for participants in the Virginia Women, Infants, and Children (WIC) Program. This program emphasizes the importance of breastfeeding as the best feeding method for infants while also providing specific formula options for those who require them. The form facilitates the issuance of special formulas, nutritionals, and modified food benefits for infants and children with medical needs. Due to a contract with Abbott Nutrition, the program primarily offers Similac Advance and Similac Soy Isomil formulas, which means that standard formulas from other manufacturers cannot be provided. If a participant needs a formula outside of these options, the WIC 395 form must be completed to ensure that their specific dietary requirements are met. It is essential for healthcare providers to understand that a new form is required at each certification appointment or when changes to the food prescription are necessary. This form not only helps in managing nutritional needs but also allows participants to continue receiving age-appropriate WIC supplemental foods as indicated by their medical condition. The Virginia WIC program is committed to supporting the health of women, infants, and children, ensuring that they receive the necessary nutrition to thrive.
Virginia WIC Request for Special Prescription
WIC-395 Form
Requests are subject to approval based on Virginia WIC policy.
Additional information located at www.vdh.virginia.gov/wic/healthcare-providers
Full completion of Sections A – E required at submission
INFANT FORM
A. Patient Information
Infant Name:
DOB:
Guardian Name:
Phone: ( )
B. Anthropometric Data
Provide most recent data collected on the same date.
Both values are required.
Weight: lbs. oz. Length: in.
Collection Date:
C.Formula Information Please include ALL products requested for patient on single form
Product(s) requested:
Is RTF medically required?:
☐ No
☐ Yes
If yes, provide RTF justification:
Amount per day: ☐ Standard WIC amount or
oz/day
Calories per ounce: ☐ Standard dilution
or
kcal/oz
Length of use: ☐ 1 month
☐ 2 months
☐ 3 months
☐ 4 months
☐ 5 months
☐ 6 months
Diagnosis with ICD code:
The following are considered non-qualifying conditions and will not be approved- colic, constipation, diarrhea, gas, fussiness, weight loss, slow or poor weight gain, non-specific feeding difficulties, spitting-up, vomiting, non-specific formula intolerances or allergies or personal preference.
All Failure to Thrive diagnoses must be supported by a current weight that is < 3rd percentile for age, current weight < 80% of ideal weight for height/age, or documented decrease in growth along infant’s previously defined growth curve.
WIC is a supplemental program and the formula and food benefits provided are not intended to meet the full nutritional needs of participants. Formula amounts over the standard WIC amounts are only available for infants who have qualifying Virginia Medicaid coverage and a qualifying diagnosis.
Contract WIC formulas (Similac Advance, Soy Isomil, Sensitive, Total Comfort, and Spit-up) cannot be issued in amounts over the standard WIC amount and RTF forms of these products cannot be issued for reasons related to tolerance.
D.Allowable WIC Foods Selection of at least 1 option is REQUIRED
Beginning at 6 months of age, WIC provides supplemental foods to infants in addition to prescribed formula. Please indicate any restrictions required for the duration of this prescription-
☐No restrictions or infant is under 6 months of age for duration of prescription
☐ Delay WIC foods until
☐
Remove Infant Cereal
months of age
Remove Infant Pureed Fruits/Vegetables
E. Health Care Provider Information
Printed Name:
☐ MD ☐ DO ☐ PA ☐ ARNP
Address:
Phone:
Fax:
Signature of healthcare provider authorized to
Date
write medical prescription under state law
WIC STAFF USE ONLY
Family ID:
Issuance Day:
Approved: ☐ Yes ☐ No
If no, provide details below :
Medicaid: ☐Yes ☐No
OTM: ☐Yes ☐No If yes, provide calculations:
☐ RD ☐ CPA ☐ CPPA
Staff Signature
This institution is an equal opportunity provider.
WIC-395 6/21
CHILD FORM
Child Name:
Phone: (
)
Weight:
lbs.
oz. Height:
in.
☐ No ☐ Yes
Amount per day:
Calories per ounce:
☐ Standard dilution or
Length of use:
☐ 1 month
The following are considered non-qualifying conditions and will not be approved- colic, constipation, diarrhea, gas, fussiness, weight loss, slow or poor weight gain, non-specific feeding difficulties, spitting-up, vomiting, non-specific formula intolerances or allergies, picky eating, enhancing nutrient intake or managing body weight without a documented underlying medical condition, food intolerances or allergies that can be managed with regular foods, or preference.
All Failure to Thrive diagnoses must be supported by a current weight that is < 3rd percentile for age, current weight < 80% of ideal weight for height/age, or documented decrease in growth along child’s previously defined growth curve.
WIC is a supplemental program and the formula and food benefits provided are not intended to meet the full nutritional needs of participants. Formula amounts over the standard WIC amounts are only available for children who have qualifying Virginia Medicaid coverage and a qualifying diagnosis.
D.Allowable Foods Selection of at least 1 option is REQUIRED
☐ No restrictions, issue all WIC foods in addition to formula
☐ Provide formula only, remove ALL other WIC foods
☐Remove the following WIC foods:
☐ Milk/Yogurt/Cheese
☐ 100% Juice
☐ Cereal
☐ Beans/Legumes
☐ Whole Grains
☐ Eggs
☐ Fruits/Vegetables
☐ Peanut Butter
☐Provide the following modifications in addition to the requested formula:
☐ Substitute pureed fruits/vegetables
☐ Substitute whole milk for 1% and
for regular fruits/vegetables
skim milk (age 2 and older, only)
☐Substitute 2% milk for 1% and skim milk (age 2 and older, only)
WOMAN FORM
Name:
B. Anthropometric/Clinical Data
Weight: lbs. oz. Height: in.
Collection date:
EDD or pregnancy end date:
☐ Standard dilution
Diagnosis, please select ALL that apply:
Low maternal weight gain / maternal weight loss, O26.1 pregnant women only
Hyperemesis Gravidarum, O21.0
pregnant women only
Current or pre-pregnancy BMI < 18.5, R63.6
pregnant and breastfeeding women only
☐Severe allergies, MUST specify and include ICD:
☐Other, MUST specify and include ICD:
D. Allowable Foods Selection of at least 1 option is REQUIRED
☐Canned Fish (women who are pregnant with multiples or fully breastfeeding only)
☐ Substitute whole milk for
1% and skim milk
☐Substitute 2% milk for 1% and skim milk
If no, provide details below:
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