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Attachment #3, 9.01 Special Formula Documentation (Records monitored in Crossroads) WIC Condition And ID number: 1. WIC-53 is correctly documented in Crossroads. 2. WIC-53 is filled out correctly with physician’s diagnosis, prescribed formula, number of months formula is prescribed 3. Formula prescribed is allowable medical condition per Policy 4.07 4. Reason for Ready-to-Feed (RTF) formula issuance is included in a care plan 5. RTF formula is issued correctly 6. A care plan has been documented by a CPA 7. Correct duration for the special formula is documented 15