Revised 3-2023 Connecticut WIC Program Manual

WIC 400-11 SECTION: Food Delivery

SUBJECT: Use of Medical Documentation Form

See Related Policy: 400-18 Coordination of WIC, HUSKY/Medicaid and Private Insurance for Issuance of Special/Exempt Formulas and Medical Foods POLICY A WIC Medical Documentation Form is required to provide special/exempt formula and/or medical foods. Only formulas/medical foods that are approved by USDA and the Connecticut WIC program shall be authorized for use in the Connecticut WIC program. Refer to the WIC Approved Special Formulas List. As of December 2021, participants that are dually enrolled in HUSKY/Medicaid and the WIC Program should have their special/exempt formula provided through HUSKY/Medicaid. See Policy 400-18 Coordination of WIC, HUSKY/Medicaid and Private Insurance for Issuance of Special/Exempt Formulas and Medical Foods, for more details on the process for issuance of special/exempt formulas. WIC Nutrition staff must assist dually enrolled participants in ensuring that special/exempt formula is received from HUSKY/Medicaid. If a participant (women, infant, or child), not dually enrolled in HUSKY/Medicaid and WIC requires a special/exempt infant formula or medical food due to a specific nutrition-related ICD-10 medical diagnosis, the health care provider is required to fill out the WIC Medical Documentation form. Instructions for completion are located on the back of each form. In Connecticut, only a Medical Doctor (MD), and Advanced Practice Registered Nurse (APRN) or a Physician’s Assistant (PA) who is authorized to write prescriptions in Connecticut can sign the form. Medical documentation may be provided as an original written document (prescription pad), an electronic document, or by facsimile. A WIC Nutritionist can accept a verbal order by telephone until written confirmation is received. See “Verbal Orders” below for more details. As indicated above, a WIC Medical Documentation Form is the preferred form of documentation. Formula Prescriptions

Any formula prescription received shall be followed up on promptly. If a new formula prescription order is received, the new order will invalidate any previous order. The prescription order on the WIC Medical Documentation Form shall be valid until the length of issuance has expired or for a period of twelve (12) months.

Ensure that all parts of the form are filled out, including the following: • Patient’s name • Date of birth • Name of parent or guardian • Medical rational (ICD-10) code • Prescribed formula • Name of formula and packaging if appropriate; ready to feed, powder, etc. • Caloric density when appropriate (24 cal/oz, 20 cal/oz)

Revised 3-2023 • Daily amount needed (unless ad lib) • Length of issuance • Health care provider signature with credentials and the date

A nutritionist shall, when indicated, contact the health care provider who wrote the prescription to clarify the order, to obtain any missing information, relay any concerns regarding medical rationale for the product, and/or if the daily amount needed/consumed exceeds what WIC can provide. Appropriately document your communications.

If the order is written on a prescription pad, scan into CT-WIC.

Verbal Orders

In an emergency, a verbal order may be accepted, but must be followed by appropriate documentation received by the local agency within 1 – 3 business days.

Document on the Medical Documentation form that the order is a verbal order (V.O.), date it, and sign your name. Also specify the name/credentials of the health care provider who gave the verbal order.

Example: Neocate One Plus Powder V.O. Dr. Smith, MD received by Jane Doe, WIC Nutritionist 3/30/23. Once a completed Medical Documentation Form with necessary information is obtained, a local agency CPA must sign and date the form, and scan into CT-WIC.