Oregon Women, Infants, and Children (WIC) Program

Medical Documentation Form

The Oregon WIC Medical Documentation Form (MD Form) is the primary tool used by healthcare providers to verify a participants eligibility for WIC benefits. The form collects essential medical and nutritional information that demonstrates a need for supplemental nutrition.

When a Provider Must Complete the Form

• A pregnant woman, postpartum mother, infant, or child (up to 5 years old) is applying for WIC for the first time.
• A current participant is requesting a change in benefits (e.g., switching from vouchers to formula).
• Annual recertification requires an updated medical assessment.

Key Sections of the Form

Section	What to Include
Participant Information	Name, DOB, address, contact details, and relationship to the household.
Pregnancy Details (if applicable)	Gestational age, prenatal vitamins, any complications (e.g., hypertension, diabetes).
Infant/Child Health	Birth weight, current weight/length, growth percentiles, diagnosis of low birth weight, prematurity, or failure to thrive.
Medical Diagnoses	Conditions that qualify for WIC, such as anemia, iron deficiency, thyroid disease, or other medicallydocumented nutritionrelated problems.
Nutrition Counseling	Brief summary of counseling provided, recommended dietary changes, and followup plan.
Provider Certification	Signature, title, license number, and date of completion.

Providers must sign and date the form; electronic signatures are accepted when the agency uses a certified esignature system. All fields must be legible; illegible or incomplete entries can delay eligibility determination.

Submitting the Form

Completed forms can be submitted in three ways:

1. Fax: Send to the local WIC agency fax number. Include the participants enrollment number if known.
2. Secure Email: Use the encrypted email address listed on the Oregon WIC website. Attach a PDF of the completed form.
3. InPerson: Drop the printed form at any WIC office or health department that processes WIC referrals.

After receipt, the WIC office reviews the documentation, contacts the provider if clarification is needed, and updates the participants record within 710 business days.

Approved Infant Formula for Oregon WIC

When a participants infant qualifies for formula assistance, WIC provides a list of approved brands and types. The list is updated annually based on the United States Department of Agriculture (USDA) Food and Nutrition Service (FNS) guidelines and statespecific contracts.

How Formula Eligibility Is Determined

• The medical documentation must indicate a condition that requires formula (e.g., premature birth, reflux, cows milk protein allergy, or inability to breastfeed).
• The provider must include the specific diagnosis and recommended formula type on the MD Form.
• WIC/NDH (Nutrition and Diabetes Health) staff verifies that the requested formula matches an approved product.

Categories of Approved Formulas

Category	Typical Use	Examples (2024)
Standard CowMilk Based	Healthy term infants 012 months	Enfamil NeuroPro, Similac Advance, Nutramigen (if no allergy)
Premature/LowBirthWeight	Infants <37 weeks gestation or <2,500g	Enfamil Premature, Similac NeoSure
Hypoallergenic (HA) / Amino Acid	Confirmed cows milk protein allergy or severe intolerance	Nutramigen, Alimentum, Neocate
SoyBased	Infants with lactose intolerance or parental preference	Similac Soy, Enfamil ProSobee
Specialty Metabolic	Specific metabolic disorders (e.g., galactosemia)	GalactAid, KetoCal

Ordering Process

1. Once eligibility is confirmed, the participant receives a Formula Voucher (paper or electronic) indicating the approved brand and quantity.
2. Vouchers can be redeemed at any participating Oregon pharmacy or grocery store that stocks the approved formula.
3. Participants may receive up to 12 cans per month, depending on the infants age and weight. The exact allotment is listed on the voucher.
4. When the voucher expires, the provider must submit a followup MD Form if the infants condition changes.

Common Questions

• Can I choose a different brand? No. WIC benefits cover only the brands on the approved list. Outoflist purchases must be paid for by the participant.
• What if the pharmacy is out of stock? The participant should call another authorized retailer. WIC staff can provide a list of nearby locations.
• Can I get formula for a sibling? Only the infant or child who meets the medical criteria receives WIC formula assistance.
• Are there limits on the number of cans? Yes. Limits are based on age, weight, and the specific formula type. Exceeding the limit will result in a partial benefit payment.

Resources for Providers and Participants

• Oregon WIC Official Site downloadable MD Form PDFs and contact numbers.
• USDA Food and Nutrition Service WIC Formula List national reference for approved formulas.
• Phone: 18008473676 WIC Help Line (available MonFri, 8am5pm PT).
• Local WIC Office ask for a Formula Benefits Coordinator for realtime assistance.

Key Takeaways

• The Oregon WIC Medical Documentation Form must be fully completed, signed, and submitted promptly to avoid delays.
• Eligibility for formula is strictly tied to a documented medical condition and must match an approved formula category.
• Only the brands listed on the current approved list can be purchased with WIC vouchers; substitutions are not permitted.
• Keep copies of all documentation and monitor voucher expiration dates to maintain uninterrupted nutrition support.