Woodford County, IL · Woodford County
Illinois WIC Formula and Medical Nutritional Prescription
Healthcare providers complete this prescription form to request medically prescribed formula and specify food options for an infant or child in the WIC program.
At a glance
- Issued by
- City of Woodford County · Woodford County, Woodford County, Illinois
- Notarization
- Not required: file this form without a notary.
- Official source
- woodford-county.org
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form lets a healthcare provider prescribe formula and select food options for an infant or child receiving Illinois WIC services. It asks for patient details, measurements, formula and food choices, a qualifying medical condition, prescribed amount and duration, and the provider’s information and signature. The form states that a healthcare provider must complete it in its entirety to receive medically prescribed formula.
Who needs it
A physician, physician assistant, or advanced practice nurse practitioner completes the form for an infant or child needing medically prescribed formula.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This form is signed and dated by the healthcare provider without a notary; no notarized attachment or related step is mentioned.
How to submit this form
- 1
Download the Form
Download the Illinois WIC Formula and Medical Nutritional Prescription PDF.
- 2
Complete the Patient Sections
Enter patient details and measurements, then select formula and food options and provide the diagnosis, amount, and duration.
- 3
Complete Provider Information
The healthcare provider completes the form, enters contact and office information, and signs and dates it.
- 4
Check for Attachments
The form does not list any attachments.
- 5
Submit to the County
Submit it to the county department named on the form; check the county website for current contact details.
Frequently asked questions
- Who completes the Illinois WIC formula prescription?
- A healthcare provider (physician, physician assistant, or advanced practice nurse practitioner) must complete the form in its entirety.
- What information does the form request?
- It requests patient details and measurements, formula and food choices, a qualifying medical condition, prescribed amount and duration, and healthcare provider information and signature.
- Do I need a notary for the Illinois WIC formula prescription?
- No. The healthcare provider signs and dates the form without a notary, and the form does not mention a notarized attachment or related step.
- How do I submit the Illinois WIC formula prescription?
- The form does not specify a submission destination. Submit it to the county department named on the form; check the county website for current contact details.