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Virginia Wic 395 Form

The Virginia WIC 395 form is a critical instrument utilized by the Commonwealth of Virginia's Women, Infants, and Children (WIC) Program to ensure that infants, children, and women who require special dietary products due to medical conditions receive the necessary supplements. Primarily, this form allows healthcare professionals to prescribe specialized formula and food products that are not typically provided standardly by the program due to contractual limitations with specific manufacturers. Efficient completion and submission of the Virginia WIC 395 form are imperative to facilitating the health and nutritional needs of the WIC participants under their care.

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Content Overview

The Virginia Women, Infants, and Children (WIC) Program plays a pivotal role in advocating for breastfeeding as the foremost nutritional choice for infants, acknowledging its significant health benefits. However, when breastfeeding is not possible and formula feeding becomes necessary, Virginia WIC provides specific formula options through a contract with Abbott Nutrition, namely Similac Advance and Similac Soy Isomil, at a special price. This strategic move allows the program to extend its resources to a broader group of participants. The Virginia WIC 395 form emerges as a critical tool in this context, designed to accommodate requests for special formulas or nutritional needs that deviate from the standard offerings due to medical exigencies. The form requires detailed information about the participant, including current anthropometric data and a medical diagnosis, to justify the need for alternative formulas or supplemental food modifications. This comprehensive approach ensures that all participants, especially those with unique health challenges, receive the tailored nutritional support they necessitate. The form underscores the program's adaptability in meeting diverse dietary needs while promoting optimal health outcomes for women, infants, and children across Virginia. It also highlights the procedural aspect, noting that a new form must be submitted at each certification appointment or upon request for any changes, reinforcing the program's commitment to ongoing support and care. Through this meticulous process, Virginia's WIC program demonstrates a steadfast dedication to nurturing the well-being of its participants, underlined by a robust framework for addressing specialized nutritional requirements.

Preview - Virginia Wic 395 Form

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

kcal/oz

Length of use: ☐ 1 month

☐ 2 months

☐ 3 months

☐ 4 months

☐ 5 months

☐ 6 months

Diagnosis with ICD code:

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
		☐	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:

Printed Name:

☐ RD ☐ CPA ☐ CPPA

Staff Signature

Date

This institution is an equal opportunity provider.	WIC-395 6/21

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

CHILD FORM

A. Patient Information

Child Name:

DOB:

Guardian Name:

Phone: (

)

B. Anthropometric Data

Provide most recent data collected on the same date.

Both values are required.

Weight:

lbs.

oz. Height:

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:

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, 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.

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)

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:

Printed Name:
	☐ RD ☐ CPA ☐ CPPA


Staff Signature	Date

This institution is an equal opportunity provider.	WIC-395 6/21

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

WOMAN FORM

A. Patient Information

Name:

DOB:

Phone: (

)

B. Anthropometric/Clinical Data

Weight: lbs. oz. Height: in.

Collection date:

EDD or pregnancy end date:

C.Formula Information Please include ALL products requested for patient on single form

Product(s) requested:

Amount per day:

oz/day

Calories per ounce:

☐ Standard dilution

kcal/oz

Length of use:

☐ 1 month

☐ 2 months

☐ 3 months

☐ 4 months

☐ 5 months

☐ 6 months

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

☐ 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

☐Canned Fish (women who are pregnant with multiples or fully breastfeeding only)

☐Provide the following modifications in addition to the requested formula:

☐ Substitute pureed fruits/vegetables	☐ Substitute whole milk for
for regular fruits/vegetables	1% and skim milk

☐Substitute 2% milk for 1% and skim milk

E. Health Care Provider Information

Printed Name:

☐ MD ☐ DO ☐ PA ☐ ARNP

Address:

Phone:

Fax:

Signature of healthcare provider authorized to	Date
Signature of healthcare provider authorized to
write medical prescription under state law

WIC STAFF USE ONLY

Family ID:	Issuance Day:

Approved: ☐ Yes ☐ No	If no, provide details below:

Printed Name:
	☐ RD ☐ CPA ☐ CPPA

Staff Signature

Date

This institution is an equal opportunity provider.	WIC-395 6/21

⇓ Virginia Wic 395 File

File Specs

Fact Name	Detail
Form Purpose	The Virginia WIC-395 form is used for requesting special food prescriptions for participants who cannot consume the standard formula options due to medical conditions.
Exclusivity of Formulas	Virginia WIC primarily provides Similac Advance and Similac Soy Isomil due to a special pricing agreement with Abbott Nutrition, limiting the provision of other standard formulas.
Alternative Formula Availability	For infants with specific intolerances or digestive issues, alternative formulas such as Similac Sensitive and Similac Spit-up are available under WIC policy.
Governing Law and Policies	Prescriptions and formula provision are subject to approval based on Virginia WIC policy and procedures, indicating adherence to both state regulations and program guidelines.
Supplemental Food Adjustments	In addition to formula, the WIC-395 form allows healthcare providers to prescribe modifications to the standard issuance of supplemental foods to meet the specific nutritional needs of participants.

Guide to Using Virginia Wic 395

Filling out the Virginia WIC 395 form is a straightforward process that facilitates the provision of special food prescriptions for infants, children, and women under the WIC program. This form is essential for healthcare professionals who are caring for participants requiring special formula or nutritional needs not met by the program's standard offerings. Once completed, the form represents a critical step towards ensuring that the dietary requirements of the most vulnerable are met, affirming the program's commitment to health and nutrition. Here's how to properly complete the form:

Participant Information: Start by entering the participant's name and date of birth at the top of the form. Include the parent or caregiver's full name in the designated space.
Current Anthropometric Data: Fill in the participant's current weight, length/height, and hemoglobin/hematocrit levels, ensuring that these are up to date. Remember to include the date these measurements were assessed.
Alternative Routine Infant Formulas: Check the appropriate box if the infant has intolerances to the standard formulas provided by WIC, choosing from Similac Sensitive Powder, Spit-up Powder, Total Comfort Powder, and their ready-to-feed (RTF) counterparts. Note that RTF products require additional justification for issuance according to WIC policy.
Exempt Infant Formulas/Nutritionals: If an exempt formula or nutritional product is required, specify the product name, form (powder, concentrate, RTF), and diagnosis with its corresponding ICD code. Remember, symptoms like colic or constipation without an underlying medical condition are not accepted for special formula issuance.
Calories Per Ounce and Ounces Per Day: Indicate whether standard dilution is sufficient or specify a different caloric density and daily amount, if necessary, keeping in mind WIC's maximum limits and special allowances for certain medical conditions.
WIC Supplemental Foods: Decide whether the participant should receive the full provision of age-appropriate WIC supplemental foods, no supplemental foods (providing formula/nutritional only), or with specific modifications (e.g., omission of certain foods). Mark any necessary modifications for infants, children, and women as applicable.
Length of Use: Specify the duration for which the special food prescription is necessary, whether it's for the entire certification period (up to 1 year) or a specified number of months.
Health Care Provider’s Information: Provide the healthcare provider’s name, address, phone, and fax number. A signature from the healthcare professional authorized to write medical prescriptions under State law is required, confirming the completion and accuracy of the form.

After the form is filled out, it needs to be submitted to either the State WIC Office or the local office where the participant is enrolled. Completing and properly submitting this form ensures that the participant receives the nutritionally appropriate formula or food, aligning with their health needs and medical condition. It's an essential step in supporting the overall goal of the WIC program to promote health and nutrition among women, infants, and children in Virginia.

Key Facts about Virginia Wic 395

What is the Virginia WIC 395 form used for?

The WIC 395 form is intended for healthcare professionals to request special food prescriptions for infants, children, and women who are participants in the Virginia Women, Infants, and Children (WIC) Program and who have medical conditions that necessitate the use of special formulas or modified food benefits. This includes the need for exempt infant formulas, additional nutritionals, or changes in food provisioning due to dietary restrictions or medical requirements.

What formulas are typically provided by Virginia WIC?

Virginia WIC primarily provides Similac Advance and Similac Soy Isomil. These formulas are available at a special price due to a contract with Abbott Nutrition, which helps the WIC program to serve more participants within the state. These are deemed optimal for most infants unless a medical condition suggests otherwise.

Can participants receive formulas other than Similac Advance and Similac Soy Isomil?

Yes, if there are medical justifications for not using the standard WIC-provided formulas, such as lactose sensitivity, excessive spit-up, or other digestive issues, healthcare providers can request alternative formulas like Similac Sensitive, Similac Spit-up, or Similac Total Comfort through the WIC-395 form. Certain conditions and additional justification might be required for ready-to-feed (RTF) products.

What is required for a special food prescription to be issued?

To issue a special food prescription, a completed WIC-395 request form is required. This includes detailed patient information, current anthropometric data, and a section specifying the need for exempt formulas or nutritional needs, supported by a medical diagnosis. Health care professionals must also specify if there will be modifications to the standard WIC food issuance.

How often does the WIC-395 form need to be renewed?

A new WIC-395 form must be submitted at each subsequent WIC certification appointment for the participant or at the end of the duration indicated in the prior form, whichever comes first. Additionally, any time there is a change to the food prescription, a new form must be filled out and submitted for approval.

Where can healthcare providers find the list of approved Formulas/Nutritionals?

The current Virginia WIC Formulary of approved Formulas/Nutritionals can be found on the Virginia Department of Health's website. This resource provides detailed information on the specific formulas and nutritional products that are available through the WIC program, including both the standard and alternative options for participants with special medical needs.

What are the standard WIC formula/nutritional amounts?

For infants and women, Virginia WIC provides specific monthly formula/nutritional amounts based on the participant's age and category. These are approximately:

0-3 months: Up to 806 fl oz (about 26 fl oz/day)
4-5 months: Up to 884 fl oz (about 29 fl oz/day)
6-11 months: Up to 624 fl oz (about 20 fl oz/day)
Children and Women: Up to 910 fl oz (about 30 fl oz/day)

Can the WIC-395 form be used for modifications to WIC supplemental foods?

Yes, the form allows healthcare providers to request modifications to the standard issuance of WIC supplemental foods. These modifications can include the provision of formula only, the omission of specific food groups such as infant cereal, fruit and vegetables, or meats, and adjustments based on medical or dietary restrictions.

How can healthcare professionals submit the WIC-395 form?

Healthcare professionals should complete the WIC-395 form with all the required information and submit it through the appropriate channels, usually directly to the State WIC Office or the local office serving the participant. Contact details for submission can be found on the Virginia Department of Health’s WIC page or by contacting the State WIC Office directly at (804) 864-7800.

Common mistakes

Filling out forms with precision is crucial, especially when it involves healthcare and nutritional support, as seen with the Virginia WIC 395 form. This document is essential for healthcare professionals who are requesting special food prescriptions for individuals under their care within the Virginia Women, Infants, and Children (WIC) Program. However, mistakes can easily be made, which might delay or hinder access to necessary nutritional support. Below are the common errors to avoid when completing this form:

Not providing complete Participant Information, including full names and date of birth. This basic yet crucial information helps to ensure that the request is matched to the correct participant in the WIC program.
Incorrect or missing Current Anthropometric Data. Accurate measurements of weight, length/height, and Hgb/Hct levels are vital for assessing the participant’s nutritional needs and for tracking progress.
Failing to specify the appropriate Alternative Routine Infant Formulas or exempt infant formulas/nutritionals. It's important to select a suitable formula based on the infant's medical needs, and not providing specific product names can lead to disparities in care.
Omitting the Diagnosis with its respective ICD Code. This information is key to justifying the need for specialized nutritional support and ensuring that the prescribed formula meets the participant's health requirements.
Not clearly indicating if there is an intolerance to standard Virginia WIC-provided formulas like Similac Advance or Similac Soy Isomil, when applicable. Without this explicitly stated, the special dietary needs might not be adequately met.
Inaccurate specification of Calories Per Ounce and Ounces Per Day, which are critical for determining the quantity of formula that needs to be issued to meet the participant’s nutritional demands effectively.
Misunderstanding or incorrectly completing the section on WIC Supplemental Foods. This part of the form allows for the customization of the participant’s food package, which is pivotal for those with particular dietary needs or restrictions.
Forgetting to set the Length of Use. This is necessary to determine how long the participant will require the special food prescription, providing a timeline for reevaluation and ensuring continuous care.

It's paramount for healthcare professionals to review the Virginia WIC 395 form meticulously before submission. Ensuring the accuracy and completeness of every section not only facilitates a smoother process but also significantly impacts the well-being of participants who rely on the WIC program for nutritional support.

Documents used along the form

When health care professionals and caregivers work with the Virginia Women, Infants, and Children (WIC) Program, particularly for special food prescriptions utilizing the WIC-395 form, several supporting documents and forms are often required to ensure comprehensive care and accurate WIC provisioning. These documents not only support the initial request but also help in maintaining a thorough record for ongoing nutritional support, addressing any changes in the patient's health status or dietary needs.

Medical Documentation of Diagnosis: This document provides detailed information on the patient's medical condition that necessitates special dietary requirements. It includes diagnosis, ICD codes, and any relevant medical history.
Proof of Income Documentation: To qualify for WIC benefits, applicants must provide proof of income. This documentation ensures that the patient meets the income eligibility requirements set by the Virginia WIC program.
Proof of Residency: Applicants are required to demonstrate residency within the state of Virginia. This could be in the form of utility bills, rental agreements, or any official document bearing the applicant's name and current address.
Immunization Records (for children): While not directly related to nutrition, WIC participants are encouraged to keep immunization records up-to-date. This requirement aligns with WIC's goal of promoting overall health and wellbeing among infants and children.
Growth Monitoring Charts: Charts that track the growth and development of an infant or child are critical for adjusting nutritional needs and interventions over time. These help in identifying any deviations from standard growth patterns that need to be addressed.
Nutrition Assessment Form: A comprehensive form that evaluates the dietary needs, preferences, and restrictions of the WIC participant. It includes information on allergies, intolerances, and specific nutritional requirements based on the individual's health condition.

Together, these forms and documents play a vital role in the meticulous process of approving and customizing the nutritional support provided to eligible participants of the Virginia Wic 395 Form. It ensures that every individual's unique health needs are met while adhering to program guidelines and regulations.

Similar forms

The Virginia WIC 395 form is similar to other forms and documents used within health and nutrition assistance programs for their specificity in nutritional requirements and the process for obtaining special dietary products. This form, particularly, is designed for healthcare professionals to request special food prescriptions for participants of the Women, Infants, and Children (WIC) Program, emphasizing the need for specific nutritional products based on medical conditions or dietary restrictions.

One document similar to the Virginia WIC 395 form is the Pediatric Nutrition Prescription Form used by hospitals and clinics. This document is utilized by healthcare providers to prescribe specific nutritional products for pediatric patients. Similarities include the detailed information required about the patient's medical condition, the need for precise food formulations (e.g., calorie per ounce, form of the product), and the healthcare provider's certification that the prescribed food is medically necessary for the patient. Both forms serve to ensure that the dietary needs of vulnerable populations are met with accuracy and care.

Another document that shares characteristics with the Virginia WIC 395 form is the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Food Prescription Form used by other states. While formats and specific contents may vary slightly from state to state, the core function remains the same: to provide health professionals with a means to prescribe specialized food products to meet the nutritional needs of women, infants, and children under the WIC program. Both documents typically require detailed patient information, a medical diagnosis, and a description of the prescribed food products, including quantity and duration of the prescription. The emphasis on medically tailored nutrition assistance highlights the personalized approach in addressing the dietary needs of program participants.

A third document comparable to the Virginia WIC 395 form is the Medical Dietary Allowance Form used by insurance companies for special dietary needs coverage. This form is filled out by healthcare providers to request coverage for special medical foods, supplements, or nutritional products that are necessary due to a medical condition. Both this form and the WIC 395 share the goal of providing individuals with necessary nutritional support based on medical advice, showcasing the intersection of healthcare, nutrition, and assistance programs. Although coming from different sectors—one from a health assistance program and the other from an insurance perspective—both documents underscore the need for accurate and detailed medical and dietary information to support individual health requirements.

Dos and Don'ts

When filling out the Virginia WIC 395 form, individuals should be attentive to detail and ensure the accuracy of the information they provide. To aid in this process, here is a list of do's and don'ts:

Do thoroughly review the instructions provided within the form to ensure a clear understanding of the requirements and necessary information.
Do accurately fill in the participant's name, date of birth, and the parent/caregiver's information to prevent any delays in processing.
Do provide current and accurate anthropometric data, including weight, length/height, and hemoglobin/hematocrit levels, as these are critical for assessing the participant’s nutritional needs.
Do consult the Virginia WIC Formulary of approved Formulas/Nutritionals, available online, to ensure the requested items are covered by the program.
Don't select alternate routine infant formulas or exempt formulas/nutritionals without a valid diagnosis and supporting medical documentation, as described in sections C and D of the form.
Don't overlook the need for an ICD code when required, as failure to include this information can result in the request being denied or delayed.
Don't request additional quantities or special formulas without providing a justification that meets both Medicaid Coverage and Diagnosis Criteria, especially for requests exceeding standard WIC amounts.
Don't forget to provide the health care provider’s information, including their name, phone number, and address, as well as ensuring the form is signed by a professional authorized to write medical prescriptions under state law.

Adhering to these guidelines will help facilitate a smoother request process for special food prescriptions under the Virginia WIC program. Proper completion of the WIC-395 form ensures that participants receive the appropriate nutritional support while also enabling the program to efficiently manage its resources.

Misconceptions

Understanding the Virginia WIC 395 form and its processes involves clearing up some common misconceptions. These misunderstandings can affect both healthcare professionals and participants of the Women, Infants, and Children (WIC) Program.

Only standard infant formulas are available through Virginia WIC. Contrary to this belief, the Virginia WIC program offers Similac Advance and Similac Soy Isomil as primary formula options due to a special pricing agreement with Abbott Nutrition. However, for infants with medical conditions that require different nutrition, special formulas can be prescribed through the WIC-395 form.
Any formula can be requested if the preferred one isn't available. This is not accurate; the program has specific alternative formulas available for infants with lactose sensitivity or digestive issues. These alternatives include Similac Sensitive Powder and Similic Total Comfort Powder, among others. Requests for formulas not listed require a medical diagnosis and are subject to Virginia WIC policy.
A WIC-395 form is a one-time requirement. Actually, a new WIC-395 request form is needed at each subsequent WIC certification appointment or at the end of the duration indicated on the form, whichever comes first. Additionally, any time a change to the food prescription is requested, a new form must be submitted.
WIC 395 form is for formula prescriptions only. While it is a crucial component for prescribing special formulas, the WIC-395 form also allows healthcare providers to recommend modifications to the supplemental food package for children and women, tailoring nutritional support to meet specific health needs.
Special formula prescriptions are guaranteed upon request. Submission of a WIC-395 form does not automatically guarantee the provision of the requested formula or nutritional modifications. All prescriptions are subject to approval based on the child's medical need and in accordance with Virginia WIC policies and procedures. Diagnosis must be provided, and standard WIC-qualifying conditions apply.

Dispelling these myths ensures healthcare professionals provide accurate guidance to families navigating the Virginia WIC program, ensuring participants receive the nutritional support best suited to their needs.

Key takeaways

Understanding the process and requirements for filling out the Virginia WIC 395 form is crucial for healthcare professionals who are involved in the care of participants in the Virginia Women, Infants, and Children (WIC) Program. Here are key takeaways that can help ensure the process is handled correctly and efficiently:

The Virginia WIC Program prioritizes breastfeeding but provides specific formulas, such as Similac Advance and Similac Soy Isomil, due to a special pricing agreement with Abbott Nutrition.
A WIC-395 request form must be completed to prescribe special formulas or nutritional products for infants with medical conditions, or when special dietary needs are identified for children and women in the WIC program.
Participants prescribed special formulas or dietary adjustments continue to be eligible for other age-appropriate WIC supplemental foods, as medically indicated.
A new WIC-395 form is required at every subsequent certification appointment for the participant or whenever there's a need to change the prescription details.
Contract infant formulas available for intolerance or digestive issues include alternatives such as Similac Sensitive and Similac Total Comfort, in powder and Ready To Feed (RTF) forms, with RTF issuance subject to WIC Policy.
Prescriptions for exempt infant formulas or nutritionals need a clear diagnosis and corresponding ICD code; symptoms like spitting-up or constipation without an underlying medical condition are not sufficient for WIC to provide specialty formulas.
WIC does not support formula prescriptions intended solely for nutrient enhancement or bodyweight management without a specific medical diagnosis.
Healthcare providers must indicate whether the patient should receive the full provision of age-appropriate WIC supplemental foods, formula/nutritional only, or a modified provision of supplemental foods.
The duration of the special food prescription can be set for up to 1 year or for a specific number of months, requiring renewal or reassessment for continued support.

Following these guidelines when completing the WIC-395 form not only supports the health and nutritional needs of the WIC participants but also ensures compliance with Virginia WIC policies and procedures. Healthcare professionals play a critical role in this process, providing the necessary medical expertise and documentation to support the specialized dietary needs of women, infants, and children in Virginia.

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