Similac Special Care 30cal 2oz RTF (infant) Similac PM 60/40 powder (infant/children) PurAmino powder 14.1oz (infants/children) Pregestimil 16oz powder (infant/children) Pediasure w/fiber ScFos Enteral 8oz RTF (child) Gerber Graduates Soy pwd 24 oz (children) Gerber Graduates Protect pwd 22 oz (children) Gerber Graduates Gentle Toddler pwd 22 oz (children) Neosure RTF 32 oz 22 cal/per/oz (infants) Pediasure w/fiber RTF 8 oz vanilla(child) Pediasure RTF 8 oz multiple flavors 6 pk(child) Neocate Jr powder 14oz (trop frt,choc,strawbry) Neocate DHA/ARA powder 14.1oz (infant/child) Neosure Expert Care pwd 13.1 oz 22 cal (infant/child) Gerber Good Start Soy RTF 8.45 oz 4 pk (infant/child) Gerber Good Start Soy Concentrate 12.1 oz (infant/child) Gerber Good Start Soy powder 12.9 oz (infant/child) Hominex 1 powder 14.1oz (infants/children) Gerber Good Start Soothe powder 12.4 oz (inf/child) Gerber GS Premature 24 cal RTF 3oz (infants)

Gerber Good Start Gentle for supplementing 12.4 oz Gerber GS Gentle RTF 8.45 oz 4pk( infant/child) Gerber GS Gentle powder 12.7 oz (infant/child) The following formulas are available from NM WIC (Women, Infants & Children)Īlimentum powder 16oz 22 cal/per/oz (infants/children)īoost Kid Essentials 1.5 w/fiber 8oz (children)īoost Kid Essentials 8.25oz – van/choc (children)īright Beginnings Soy RTF 8 oz (children)Įlecare DHA/ARA 14.1 oz powder (infants/child)Įnfacare powder 12.8oz 22 cal/per/oz (infants/children) Please return this form to participant’s WIC clinic. New Mexico Medical Request for Formula/Foodįor MEDICAL FORMULA AND FOOD: Complete Section Bįor HEALTH CARE PROVIDER SIGNATURE: Complete Section C *Maximum allowed by federal guidelines (6 months) will be provided unless otherwise indicated ***NOT ALLOWED: constipation, diarrhea, unconfirmed allergies, or for managing body weight, lactose intolerance symptoms, or growthĬoncerns unless there is an underlying medical condition.ĭate: _ Length/Height _Weight _ If premature: Birth Weight _Weeks Gestation_ī. Other medical condition: _ICD-9 code: _ 360 Seizure disorder requiring ketogenic diet (345.90) 348 Lactose or Sucrose Intolerance (271.3) 355 Qualifying Condition/Diagnosis/ICD-9code: _Īllergy, confirmed (693.1) 353 Autoimmune Disorder (279.4) 352Ĭongenital Anomaly, Respiratory (748.9) 360 Congenital Heart Disease (746.9) 360ĭevelopmental Sensory/Motor Delays (783.40) 362įailure to Thrive (C-783.41, W-786.7) 134 Gastroesophageal Reflux (580.81) 342 New Mexico WIC Medical Request for Formula/Foodĭirections for completing this form and other information are on reverse side.Īll requests are subject to WIC approval and provision based on program policy and procedure Landlord (Tenant) Recommendation Letter.

Nm wic approved foods