Welcome to the State of California 

WIC Infant Formula: Therapeutic Formula


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
  • Therapeutic Formula fax cover page for Local Agencies Fax Cover Page (WORD)
  • WIC Program Manual Policies for Therapeutic Formula and Medical Foods: 
  • Common Indications for Therapeutic Formula (PDF)(also see the Formula Product Information links below)
  • For additional information regarding Therapeutic Formula, please contact Denay.Mintz@cdph.ca.gov phone 916-928-8762.  For additional information regarding Medi-Cal, please contact Cheryl.Barrios@cdph.ca.gov phone 916-928-8579.

    Formula Product Information Links
    Last modified on: 9/28/2016 3:27 PM