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WIC Infant Formula: Therapeutic Formula

Procedures

Processing Therapeutic Formula Requests:

  • Process for Therapeutic Formula Requests (PDF)"Opens a new browser window"
  • Pediatric Referral Form  Full Sheet Version (PDF)Opens a new browser windowwith Instructions (PDF)Opens a new browser window
  • Infant Screening and Medical Justification for Therapeutic Formulas Form  CDPH 4143 (PDF)"Opens a new browser window"
  • Child Screening and Medical Justification for Therapeutic Formulas Form CDPH 4144 (PDF)"Opens a new browser window"
  • WIC Program Manual Policies for Therapeutic Formula and Medical Foods: 
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  • Common Indications for Therapeutic Formula (PDF)also see the Formula Product Information links below
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    For additional information, please contact Denay.Mintz@cdph.ca.gov phone 916-928-8762 or Paula.Etcheberry@cdph.ca.gov phone 916-928-8539.

    Formula Product Information Links
     
     
    Last modified on: 5/17/2012 3:27 PM