765.1 Policy 765 Medical Documentation July 1, 2025 POLICY Local agencies shall issue approved medical formulas and nutritionals and supplemental foods to adult participants, infants and children with medical documentation from a health care provider. PURPOSE To comply with federal requirements for medical documentation for issuance of approved medical formula and nutritionals and any supplemental foods, and to facilitate coordination of care for all WIC participants with qualifying medical conditions. RELEVANT REGULATIONS 7 CFR §246.10 ¶(d)(1)—WIC Formulas and Supplemental foods requiring medical documentation OREGON WIC PPM REFERENCES ♦ 760—Medical Formulas and Nutritionals DEFINITIONS Competent Professional Authority (CPA): An individual on the staff of the local WIC program authorized to assess program eligibility, determine nutritional risk, provide nutrition education and counseling, and prescribe supplemental foods. Medical formula: A formula in which the composition meets the special nutrient requirements of infants, children or adults diagnosed with various medical diseases and conditions. For infants, the medical formula may not meet the complete nutrient specifications defined by the Food and Drug Administration in the Infant Formula Act. The term, medical formula, is also known by the regulatory term, “exempt infant formula”. Standard infant formula: A formula for infants that meets the nutrient specifications defined in the Infant Formula Act. These formulas meet the nutritional needs of healthy, term infants from birth to one year of age. Standard infant formulas are also known as “term formula” and “regular infant formula”, and “non-exempt” formulas. WIC-eligible nutritionals: Enteral products that are specifically formulated to provide nutrition support for children over 1 year of age and adult participants with a diagnosed medical condition, when the use of conventional foods is precluded, restricted, or inadequate. Also known as WIC-eligible medical foods. Nutritionals may be nutritionally complete or incomplete (e.g. Duocal). They must serve the purpose of a food, provide a source of calories and one or more nutrients, and be designed for enteral digestion via an oral or tube feeding. WIC Medical Documentation Form (MDF): Documentation which includes the federal technical requirements to ensure a licensed health care professional authorized to write medical prescriptions under Oregon law has determined a medical condition/diagnosis which requires the use of a medical formula, nutritionals and changes to the participant’s

Medical Documentation, Continued 765.2 supplemental food package. This form is a request for provision, not a prescription and it replaces prescriptions from health care providers. BACKGROUND The Oregon WIC Medical Documentation form is required for all participants receiving Food Package III. Food Package III provides participants a prescribed USDA-approved medical formula or nutritional when the use of conventional foods is precluded, restricted, or inadequate to address his/her special nutritional needs. PROCEDURE Participants requiring medical documentation 1.0 Medical documentation is required for WIC participants with qualifying medical conditions to receive WIC approved formulas or nutritionals. In addition, medical documentation is required for the following:

WIC supplemental foods for participants receiving medical formula or nutritional;

Infants 6 –12 months old who receive additional formula in lieu of foods when medically indicated.

Children, after 23 months of age and adult participants receiving formula or nutritional, to also receive whole milk.

Children and adult participants receiving formula or nutritionals and a diagnosed medical need to receive infant fruits and vegetables in place of the cash value benefit and infant cereal in place of adult cereal. Qualifying conditions 2.0 Medical documentation is required for WIC participants who have a documented qualifying medical condition(s) which includes, but is not limited to, medical conditions listed in  760—Medical Formulas and Nutritionals, Appendix A in which the use of conventional foods is precluded, restricted or inadequate to address their special nutritional needs. WIC Medical Documentation Form 3.0 The WIC Medical Documentation Form accessed at https://www.oregon.gov/oha/PH/HEALTHYPEOPLEFAMILIES/WIC/Documents/636_ medical_doc.pdf 4.0 The medical documentation form is the required form for health care providers to complete, sign and return to the local WIC agency. Technical requirements for medical documentation

The medical documentation form must include the following technical requirements: 4.1.1. Name of the authorized WIC formula or WIC-eligible nutritional and the amount needed per day. 4.1.2. The authorized supplemental food(s) appropriate for the qualifying condition(s) and their prescribed amounts.

Medical Documentation, Continued 765.3 4.1.3. Length of time the prescribed WIC formula, nutritional and supplemental food is required by the participant, up to but not exceeding one year. 4.1.4. The qualifying condition(s) for issuance of the authorized formula, nutritional and supplemental food(s). 4.1.5. Signature, date and contact information of the authorized health care provider completing the medical documentation. WIC and Medicaid 5.0 Based on federal regulations:

Medicaid is the first payer of exempt infant medical formulas and nutritionals.

WIC can provide up to the maximum amount of exempt medical infant formulas and nutritionals in situations where reimbursement is not provided by another entity. 6.0 WIC can provide the maximum amount of formula and nutritionals for oral supplementation allowed in our data system as supported by a medical documentation form as long as:

Family is aware that WIC is supplemental and may not be able to provide the full formula benefit.

Attempts are made to coordinate care, when appropriate. WIC Nutritionist role in assigning supplemental foods 7.0 Due to the nature of the health conditions of participants who are issued medical formulas and nutritionals and supplemental foods, close medical supervision is essential for each participant’s dietary management. The health care provider is responsible for medical oversight. The WIC dietitian/ nutritionist will conduct a comprehensive health and nutrition assessment to determine the most appropriate food package for the participant, unless the medical documentation form indicates otherwise. It is not allowable to issue benefits for a medical formula prior to entering the medical documentation form. The CPA must obtain either a written MDF or a verbal order from the medical provider before the medical formula can be issued. A written MDF must be received within 2 weeks of obtaining the verbal order. 8.0 Document the required elements of medical documentation in the appropriate location in the WIC data system. Retain the paper copy (or electronic copy) of the MDF for six years after the last date of service or scan and upload the form into the WIC data system. Nutritional care and review of Medical Documentation Form 9.0 The Local agency WIC nutritionist or health professional shall review medical documentation forms for participants needing medical formulas or nutritionals and/or modifications to their WIC supplemental foods. See  760-Medical Formulas and Nutritionals for information on nutritional care for WIC participants with qualifying conditions.

The review and oversight of the medical documentation form by the WIC nutritionist or health professional is intended to ensure the provision of nutritional care required for participants with medical conditions. It is not

Medical Documentation, Continued 765.4 intended to impede the issuance of the formula or nutritional the participant needs for their medical condition. In cases where this provision of service is a hardship for the local agency, contact your assigned state Nutrition Consultant for additional guidance. Periodic review of medical documentation

It is recommended that the food package assignment be reviewed during each certification period and/or every three months to assess for changes to health status and appropriateness of food/formula to the participant’s medical diagnosis and to ensure current authorization.

It may be necessary for the WIC Nutritionist or health professional to contact the participant’s health care provider in order to coordinate nutrition care, to verify and update the medical formula or nutritional information, or to obtain a new authorization, if necessary. Medical documentation provided by telephone 10.0 Medical documentation may be initiated by telephone to a CPA who must promptly document the required technical information. This verbal telephone order must be documented in the WIC data system. The collection of the required information for medical documentation purposes by telephone may only be until written confirmation on the required form is received from a health care professional licensed to write medical prescriptions and used only when absolutely necessary on an individual participant basis. The local agency must obtain written documentation within two weeks of accepting the medical documentation by phone. Revisions to Medical Documentation Forms Revisions to existing medical documentation forms may be provided by an authorized health care provider by telephone to a competent professional authority during a current authorization period on a form signed by the provider. Evidence of the revision must be documented on the form and entered into the participant’s record in the WIC data system. Medical documentation from another state 11.0 When a participant transfers into Oregon with a WIC medical documentation form from another state, that form may be honored until its expiration date. It is recommended that the participant be encouraged to locate a health care provider in their community to ensure continuity of care and complete a new medical documentation form for Oregon WIC.

If you need this in large print or an alternate format, please call 971-673-0040. This institution is an equal opportunity provider.

Medical Documentation, Continued 765.5

POLICY HISTORY Date * Major Revision, Minor revision 10/13/2016 Revision 3/9/2020 Review 2/03/2025 Revision 7/01/2025 Major revision

The date located at the top of the policy is the implementation date unless an “effective date” is noted on the policy. Policies will become compliance findings 6 months from the implementation date. Release notes can be found in the corresponding document on the Policy and Procedure Manual page. *Major Revisions: Significant content changes made to policy. Minor Revisions: Minor edits, grammatical updates, clarifications, and/or formatting changes have occurred. Date of Origin: Date policy was initially released