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Section 7.6: Medical Documentation 1/2023 References: 7 CFR 246.10 Policy: Some formulas and supplemental foods may be provided by WIC only with appropriate medical documentation. Purpose: To assure participants receive WIC supplemental foods that meet their medical and/or nutritional needs. Procedures Medical Determination Medical determination documenting a qualifying condition is required for participants receiving Food Package 3, including: ▪ Standard contract infant formula prescribed to a child ▪ Exempt infant formula ▪ WIC-eligible medical food ▪ Supplemental foods issued to participants receiving Food Package 3. Supplemental foods are available from the standard food package for the participant’s WIC type, e.g., a child receiving Food Package 3 may receive any of the foods from Food Package 4 that are appropriate. ▪ Whole or 2% milk issued to children age 2 and over or women in Food Package 3. ▪ Infant fruit and vegetables and infant cereal provided to a child receiving medical formula Qualifying conditions. The table Foods/Formula Requiring Medical Documentation below lists the qualifying medical conditions for the issuance of medical formulas and supplemental foods. Formula and supplemental foods may not be issued for a non-qualifying condition. Medical documentation requirements ▪ Documentation must be obtained prior to issuance of:

S E C T I O N 7 . 6 : M E D I C A L D O C U M E N T A T I O N 2 ▪ medical formula using Exhibit 7-D: Minnesota WIC Program Request for Formula Documentation ▪ Medical documentation may be submitted on another form as long as all Federally required components are present. ▪ Documentation must be from a Health Care Professional licensed to write medical prescriptions under Minnesota state law. ▪ M.D. ▪ Physician’s Assistant supervised by a medical physician ▪ Certified Nurse-Midwife ▪ Nurse Practitioner (Certified Clinical Nurse Specialist) who has an agreement with a physician based on standards established by the Minnesota Nurses Association and the Minnesota Medical Association ▪ Licensed Doctor of Osteopathy duly licensed to practice medicine ▪ Health Care Provider must document in writing all the following: ▪ Qualifying medical condition; see the table Foods/Formula Requiring Medical Documentation below ▪ Name of formula and/or any WIC foods ▪ Prescribed amount(s) per day ▪ Length of time required ▪ Health Care Provider signature, date, and contact information ▪ Medical documentation must be obtained in writing as an original written document, electronically, or by fax and scanned into the participant record. ▪ Medical documentation may be provided by telephone to a CPA, when necessary to prevent a delay that would place a participant at increased nutritional risk (determined on case-by-case basis) and until written confirmation is received, which must be within 1 month. Voucher issuance is limited to one month with verbal verification. ▪ At a minimum, new documentation is required when the Health Care Provider’s intended length-of-use expires, or the prescription has changed. ▪ Transfer participants ▪ In-state transfers: CPAs may honor the medical prescription, documented by the originating local agency in the participant record, if still applicable. ▪ Out-of-state transfers: For participants who don’t have a medical prescription with them, contact their Health Care Provider or previous WIC agency to verify the medical documentation information. Prescription Renewal Requirements:

S E C T I O N 7 . 6 : M E D I C A L D O C U M E N T A T I O N 3 ▪ Prescriptions for participants receiving Food Package 3 must be obtained at least every 6 months or any time the food package changes. ▪ Evaluation of Medical Documentation: CPAs must assess the appropriateness of the formula/food requested, considering the health condition and/or diagnosis and make food package changes as appropriate. The following information should be considered for approval: ▪ Medical diagnosis or condition(s) which necessitates the need for the formula/food ▪ Approval should not be made for women and children who have a food intolerance to lactose or milk protein that can be successfully managed with the use of other WIC supplemental foods. ▪ Current growth status (i.e., weight and length/height plotted on growth chart) ▪ Pattern of growth over time, when information is available (e.g., weight gained over previous months) ▪ Health and diet history (including a diet recall) ▪ Interview with caregiver to determine if formula is prepared/stored properly ▪ Consultation with the prescribing Health Care Provider, when necessary to determine need ▪ CPA Professional Judgment: CPAs may deny a request for a formula/food if, in their professional judgment, there is no justifiable medical need. (Note: “Parental preference” and “picky eater” do not establish medical need and therefore are not qualifying conditions.) See Guidance in Section 7.9: Food Package 3. Foods/Formula Requiring Medical Documentation Participant Category Supplemental Food/Formula Requiring Medical Documentation Qualifying Medical Condition Non-qualifying Condition Infants 0-5 months Food Package 3 ▪ Exempt infant formula ▪ Medical food ▪ Premature birth ▪ Low birth weight ▪ Failure to thrive ▪ Inborn errors of metabolism ▪ Metabolic disorders ▪ Gastrointestinal disorders ▪ Malabsorption syndromes ▪ Immune system disorders ▪ Severe food allergies that require an elemental formula ▪ Life threatening disorders, diseases, and medical conditions that impair ingestion, digestion, absorption, or utilization of nutrients that could adversely affect the participant’s nutrition status ▪ Non-specific formula or food intolerance ▪ Suspected or non-confirmed allergy ▪ Only condition is a diagnosed formula intolerance or food allergy to lactose, sucrose, milk protein or soy protein that does not require an exempt infant formula, or non-specified formula or food intolerance ▪ Participant preference

S E C T I O N 7 . 6 : M E D I C A L D O C U M E N T A T I O N 4 Participant Category Supplemental Food/Formula Requiring Medical Documentation Qualifying Medical Condition Non-qualifying Condition Infants 6-12 months Food Package 3 ▪ Exempt infant formula ▪ Medical food As above As above Infants 6-12 months Food Package 3 ▪ Infant fruits and vegetables ▪ Infant cereal Health Care provider indicates complementary foods are appropriate Health Care provider indicates complementary foods are not appropriate Children 1-4 years Food Package 3 ▪ infant formula ▪ Exempt infant formula ▪ Medical food ▪ Premature birth ▪ Low birth weight ▪ Failure to thrive ▪ Inborn errors of metabolism ▪ Metabolic disorders ▪ Gastrointestinal disorders ▪ Malabsorption syndromes ▪ Immune system disorders ▪ Severe food allergies that require an elemental formula ▪ Life threatening disorders, diseases, and medical conditions that impair ingestion, digestion, absorption, or utilization of nutrients that could adversely affect the participant’s nutrition status ▪ Solely for the purpose of enhancing nutrient intake or managing body weight without an underlying condition ▪ Lactose intolerance ▪ Participant preference ▪ Food dislike Children 1-4 years Food Package 3 ▪ Milk/milk alternatives (includes whole/2% milk) ▪ Cereal ▪ Eggs ▪ Fruits & vegetables ▪ Whole grains ▪ Peanut butter/beans ▪ Juice Health Care Provider indicates supplemental foods are appropriate Health Care Provider indicates supplemental foods are not appropriate.

S E C T I O N 7 . 6 : M E D I C A L D O C U M E N T A T I O N 5 Participant Category Supplemental Food/Formula Requiring Medical Documentation Qualifying Medical Condition Non-qualifying Condition Women Food Package 3 ▪ Medical food ▪ Inborn errors of metabolism ▪ Metabolic disorders ▪ Gastrointestinal disorders ▪ Malabsorption syndromes ▪ Immune system disorders ▪ Severe food allergies that require an elemental formula ▪ Life threatening disorders, diseases, and medical conditions that impair ingestion, digestion, absorption, or utilization of nutrients that could adversely affect the participant’s nutrition status ▪ Solely for the purpose of enhancing nutrient intake or managing body weight without an underlying condition ▪ Lactose intolerance ▪ Participant preference ▪ Food dislike Women Food Package 3 ▪ Milk/milk alternatives (includes whole/2% milk) ▪ Cereal ▪ Eggs ▪ Fruits & vegetables ▪ Whole grains ▪ Peanut butter/beans ▪ Juice Health Care Provider indicates supplemental foods are appropriate Health Care Provider indicates supplemental foods are not appropriate. Reference – Complete Listing of Hyperlinks: Exhibit 7-D: Medical Formula Documentation (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/exhbts/ex7/7d. pdf) Section 7.9: Food Package 3 (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/chsctns/ch7/sct n7_9.pdf) Minnesota Department of Health - WIC Program 625 Robert St N, PO BOX 64975, ST PAUL MN 55164-0975; 1-800-657-3942, health.wic@state.mn.us, www.health.state.mn.us. To obtain this information in a different format, call: 1-800-657-3942 This institution is an equal opportunity provider.