Updated WIC medical documentation form

Washington State Health Care Authority sent this bulletin at 07/16/2025 08:00 AM PDT

July 16, 2025

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Updated WIC medical documentation form

This bulletin is being sent by the Health Care Authority (HCA) on behalf of the Department of Health (DOH) Office of Nutrition Services.

The Department of Health has updated the Women, Infants, and Children (WIC) medical documentation form (MDF), effective July 14, 2025. Updates to the form include:

Combined the 3 separate MDFs into one form for all women, infants, and children.
Added section for the patient's anthropometric measurements.
Added a section to note if you submitted a formula prescription to a pharmacy.
Removed the option to prescribe a formula for a 12-month duration. Formula prescriptions may not exceed 6 months.

What can you do to help?

Replace the old MDF with the attached/linked updated MDF.
Complete all sections and return the MDF promptly when a WIC Clinic or WIC participant requests.
Provide a verbal order when you need more time to complete the requested MDF.

You must complete all sections before returning this form to a WIC clinic. WIC staff are not able to issue medical foods or formulas without a written or verbal prescription from a medical provider.

Thank you for helping keep WIC families healthy!

View new WIC medical documentation form

Contact

Email: WA WIC Foods

About the Health Care Authority (HCA)

Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible.

There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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