Medical Documentation and Referral Form

Medical Documentation Form (WIC-27)

person writing

The Medical Documentation – Health Care Provider Authorization Form (WIC-27) is required to prescribe non-contract standard infant formula, exempt infant formula and WIC-eligible nutritionals. A health care provider’s prescription is not an allowable substitution. A qualifying condition must be present for approval.

Please use the links provided below to see a list of formulas Missouri WIC provides and then proceed to the Medical Documentation – Health Care Provider Authorization Form (WIC-27). Visit our Health Care Provider Frequently Asked Questions tab or contact your WIC local agency if you have specific questions about completing a WIC-27.

MO WIC Approved Formulas
and WIC-Eligible Nutritionals

WIC-27

Note: All prescriptions are subject to WIC approval based on WIC federal regulations and policies.

WIC Referral Form

To be eligible for WIC services, WIC participants must provide proof of pregnancy (if applicable), height and weight measurements, and blood work.

This information is sometimes requested from health care providers in order to encourage referrals to health care services. In many cases, height, weight, and hemoglobin screening can also be done at the WIC clinic during certification.

Healthcare providers, social service programs, and WIC local agency staff can use the WIC Referral Form to refer WIC participants and patients to needed services.