The Virginia WIC 395 form is a crucial document utilized within the Virginia Women, Infants, and Children (WIC) Program to request special food prescriptions for infants and children. This form enables healthcare professionals to prescribe specific formulas and nutritional products when standard options are not suitable due to medical conditions. Understanding the purpose and requirements of this form is essential for ensuring that participants receive the appropriate nutritional support they need.
The Virginia WIC 395 form plays a crucial role in the Virginia Women, Infants, and Children (WIC) Program, which emphasizes the importance of breastfeeding while also providing formula options for infants. Specifically, the program offers Similac Advance and Similac Soy Isomil due to a contractual agreement with Abbott Nutrition, which ensures a lower cost for these formulas. However, this contract limits the availability of standard infant formulas from other manufacturers, such as Enfamil and Gerber Good Start. For infants with medical conditions that necessitate special formulas or modified food benefits, healthcare providers can issue a special food prescription using the WIC 395 form. This form must be completed and submitted at each WIC certification appointment or when changes to the food prescription are needed. Participants who receive a special food prescription continue to qualify for standard WIC supplemental foods as long as they meet the medical criteria. Additional resources, including the current Virginia WIC Formulary and information about Ready To Feed formulas, are accessible online. The form also requires detailed patient information, including anthropometric data and specific dietary needs, ensuring that each participant receives appropriate nutritional support.
Filling out the Virginia WIC 395 form can be straightforward, yet many individuals make common mistakes that can delay the process or lead to denial of requests. One frequent error is failing to provide complete participant information. This includes missing the participant’s full name or date of birth. Omitting any of this crucial data can result in processing delays, as the form may be returned for correction.
Another common mistake is not including accurate anthropometric data. Participants often overlook the importance of providing precise weight, height, and hemoglobin levels. Inaccurate measurements can lead to inappropriate formula prescriptions, which may not meet the nutritional needs of the infant or child.
Many people also neglect to specify the correct diagnosis and corresponding ICD code. Providing vague or incorrect information can cause the request to be rejected. The diagnosis should clearly outline the medical necessity for the requested formula or nutritional product. Without this, the application may not meet WIC’s stringent criteria.
Additionally, individuals often fail to check the appropriate boxes related to the type of formula or nutritional products being requested. Misunderstanding the options can lead to requests for products that are not covered under the WIC program. It’s essential to review the available formulas and select the ones that align with the participant's needs.
Another area where errors frequently occur is in the section regarding WIC supplemental foods. Some applicants mistakenly choose options that do not match the participant's dietary requirements. Omitting or including inappropriate foods can complicate the approval process and affect the overall benefits received.
Moreover, people sometimes forget to include their healthcare provider’s information or fail to ensure that the provider’s signature is present. This oversight can lead to significant delays, as WIC requires a valid signature from a licensed healthcare professional to process the request.
Lastly, many individuals do not keep track of the duration of the requested formula or nutritional benefits. Failing to specify the length of use can result in confusion regarding the validity of the prescription. Clarity in this section is vital to ensure that the participant receives the necessary support for the appropriate time frame.
Virginia WIC Request for Special Prescription
WIC-395 Form
Requests are subject to approval based on Virginia WIC policy.
Additional information located at www.vdh.virginia.gov/wic/healthcare-providers
Full completion of Sections A – E required at submission
INFANT FORM
A. Patient Information
Infant Name:
DOB:
Guardian Name:
Phone: ( )
B. Anthropometric Data
Provide most recent data collected on the same date.
Both values are required.
Weight: lbs. oz. Length: in.
Collection Date:
C.Formula Information Please include ALL products requested for patient on single form
Product(s) requested:
Is RTF medically required?:
☐ No
☐ Yes
If yes, provide RTF justification:
Amount per day: ☐ Standard WIC amount or
oz/day
Calories per ounce: ☐ Standard dilution
or
kcal/oz
Length of use: ☐ 1 month
☐ 2 months
☐ 3 months
☐ 4 months
☐ 5 months
☐ 6 months
Diagnosis with ICD code:
The following are considered non-qualifying conditions and will not be approved- colic, constipation, diarrhea, gas, fussiness, weight loss, slow or poor weight gain, non-specific feeding difficulties, spitting-up, vomiting, non-specific formula intolerances or allergies or personal preference.
All Failure to Thrive diagnoses must be supported by a current weight that is < 3rd percentile for age, current weight < 80% of ideal weight for height/age, or documented decrease in growth along infant’s previously defined growth curve.
WIC is a supplemental program and the formula and food benefits provided are not intended to meet the full nutritional needs of participants. Formula amounts over the standard WIC amounts are only available for infants who have qualifying Virginia Medicaid coverage and a qualifying diagnosis.
Contract WIC formulas (Similac Advance, Soy Isomil, Sensitive, Total Comfort, and Spit-up) cannot be issued in amounts over the standard WIC amount and RTF forms of these products cannot be issued for reasons related to tolerance.
D.Allowable WIC Foods Selection of at least 1 option is REQUIRED
Beginning at 6 months of age, WIC provides supplemental foods to infants in addition to prescribed formula. Please indicate any restrictions required for the duration of this prescription-
☐No restrictions or infant is under 6 months of age for duration of prescription
☐ Delay WIC foods until
☐
Remove Infant Cereal
months of age
Remove Infant Pureed Fruits/Vegetables
E. Health Care Provider Information
Printed Name:
☐ MD ☐ DO ☐ PA ☐ ARNP
Address:
Phone:
Fax:
Signature of healthcare provider authorized to
Date
write medical prescription under state law
WIC STAFF USE ONLY
Family ID:
Issuance Day:
Approved: ☐ Yes ☐ No
If no, provide details below :
Medicaid: ☐Yes ☐No
OTM: ☐Yes ☐No If yes, provide calculations:
☐ RD ☐ CPA ☐ CPPA
Staff Signature
This institution is an equal opportunity provider.
WIC-395 6/21
CHILD FORM
Child Name:
Phone: (
)
Weight:
lbs.
oz. Height:
in.
☐ No ☐ Yes
Amount per day:
Calories per ounce:
☐ Standard dilution or
Length of use:
☐ 1 month
The following are considered non-qualifying conditions and will not be approved- colic, constipation, diarrhea, gas, fussiness, weight loss, slow or poor weight gain, non-specific feeding difficulties, spitting-up, vomiting, non-specific formula intolerances or allergies, picky eating, enhancing nutrient intake or managing body weight without a documented underlying medical condition, food intolerances or allergies that can be managed with regular foods, or preference.
All Failure to Thrive diagnoses must be supported by a current weight that is < 3rd percentile for age, current weight < 80% of ideal weight for height/age, or documented decrease in growth along child’s previously defined growth curve.
WIC is a supplemental program and the formula and food benefits provided are not intended to meet the full nutritional needs of participants. Formula amounts over the standard WIC amounts are only available for children who have qualifying Virginia Medicaid coverage and a qualifying diagnosis.
D.Allowable Foods Selection of at least 1 option is REQUIRED
☐ No restrictions, issue all WIC foods in addition to formula
☐ Provide formula only, remove ALL other WIC foods
☐Remove the following WIC foods:
☐ Milk/Yogurt/Cheese
☐ 100% Juice
☐ Cereal
☐ Beans/Legumes
☐ Whole Grains
☐ Eggs
☐ Fruits/Vegetables
☐ Peanut Butter
☐Provide the following modifications in addition to the requested formula:
☐ Substitute pureed fruits/vegetables
☐ Substitute whole milk for 1% and
for regular fruits/vegetables
skim milk (age 2 and older, only)
☐Substitute 2% milk for 1% and skim milk (age 2 and older, only)
WOMAN FORM
Name:
B. Anthropometric/Clinical Data
Weight: lbs. oz. Height: in.
Collection date:
EDD or pregnancy end date:
☐ Standard dilution
Diagnosis, please select ALL that apply:
Low maternal weight gain / maternal weight loss, O26.1 pregnant women only
Hyperemesis Gravidarum, O21.0
pregnant women only
Current or pre-pregnancy BMI < 18.5, R63.6
pregnant and breastfeeding women only
☐Severe allergies, MUST specify and include ICD:
☐Other, MUST specify and include ICD:
D. Allowable Foods Selection of at least 1 option is REQUIRED
☐Canned Fish (women who are pregnant with multiples or fully breastfeeding only)
☐ Substitute whole milk for
1% and skim milk
☐Substitute 2% milk for 1% and skim milk
If no, provide details below:
The Virginia WIC 395 form shares similarities with the Food Prescription Form used in many healthcare settings. Both documents serve as a means to prescribe specific dietary needs for individuals, particularly those with special nutritional requirements. Just as the WIC 395 form allows healthcare professionals to recommend specialized formulas for infants, the Food Prescription Form enables providers to specify food items or dietary supplements that a patient may need due to medical conditions. This ensures that patients receive the appropriate nutrition tailored to their health needs.
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Another document akin to the Virginia WIC 395 form is the Medical Release Form. While the WIC 395 focuses on dietary prescriptions, the Medical Release Form allows healthcare providers to share a patient’s medical information with other parties, such as nutritionists or specialists. Both documents require the patient's information and the healthcare provider's signature, ensuring that the patient’s nutritional and medical needs are addressed collaboratively. This cooperation can enhance the overall care provided to individuals enrolled in programs like WIC.
The Nutritional Assessment Form is also similar to the Virginia WIC 395 form. This document is typically used to evaluate a patient’s dietary intake and nutritional status. Like the WIC 395, it collects anthropometric data and may include information about specific dietary restrictions or needs. Both forms help healthcare professionals make informed decisions about the dietary interventions required to support the health of infants, children, and women, ensuring that their nutritional requirements are met effectively.
Additionally, the Supplemental Nutrition Assistance Program (SNAP) Application bears resemblance to the WIC 395 form in that both are designed to support individuals with nutritional assistance. While the WIC 395 focuses on specific food prescriptions for infants and children, the SNAP application addresses broader food assistance needs for families. Both documents require personal information, income details, and other relevant data to determine eligibility for nutritional support, thereby promoting better health outcomes for participants.
Lastly, the Special Dietary Needs Request Form aligns with the Virginia WIC 395 form by allowing healthcare providers to request specific food items or modifications for patients with dietary restrictions. Both forms require a diagnosis and details about the patient’s condition, ensuring that the recommended dietary changes are medically justified. This process helps ensure that individuals with unique dietary needs receive the appropriate foods to maintain their health and well-being.
Filling out the Virginia WIC 395 form is a straightforward process that requires specific information about the participant and their dietary needs. Follow these steps to ensure the form is completed accurately.
Once completed, review the form for accuracy before submission. This ensures that the participant receives the appropriate dietary support they need. If you have any questions, don’t hesitate to reach out to the local WIC office for assistance.
The Virginia WIC 395 form is designed to request a special food prescription for participants in the Women, Infants, and Children (WIC) program. This form is essential for those who require specific formulas or nutritional products due to medical conditions. It ensures that infants and children receive appropriate nutrition, especially if they cannot consume standard formulas provided by WIC.
The form must be completed by a healthcare professional who is authorized to write medical prescriptions. This includes doctors, nurse practitioners, and physician assistants. The healthcare provider will assess the participant's needs and provide the necessary information on the form to justify the request for special formulas or modified food benefits.
WIC primarily offers Similac Advance and Similac Soy Isomil due to a contract with Abbott Nutrition. However, if a participant has specific medical needs that require alternative formulas, the healthcare provider can request these using the WIC 395 form. Some alternative formulas available include Similac Sensitive and Similac Spit-up. It's important to note that any special formula requests must be medically justified.
A new WIC 395 form is required at each WIC certification appointment or at the end of the duration indicated on the form, whichever comes first. Additionally, if there are any changes to the food prescription during the certification period, a new form must be submitted to reflect those changes.
For further details about the Virginia WIC program, including the approved formulary of formulas and nutritionals, visit the Virginia Department of Health's WIC webpage. You can also contact the State WIC Office at (804) 864-7800 for specific inquiries or assistance related to the WIC 395 form and its use.
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