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MAINE CENTER FOR DISEASE CONTROL & PREVENTION WIC NUTRITION PROGRAM Medical Documentation for WIC Medical Formula or Medical Food/MaineCare Prior Authorization Form for Medical Formula or Medical Food Healthcare Provider
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Document Date: 2012-03-19 13:50:17

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File Size: 202,97 KB

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City

Participant / Family / /

Company

Mead Johnson / /

Event

Product Issues / /

Facility

WIC clinic / Write pharmacy / Pharmacy Name / Pharmacy NABP/NPI Number / /

/

IndustryTerm

beverage / soy beverage / food / /

MedicalCondition

Protein Hydrolysate Elemental Formula Allergy / Galactosemia / Protein Hydrolysate Lactose Intolerance / Cerebral Palsy / food allergies / Neuromuscular Disorder / Protein Hydrolysate Elemental Formula Dermatitis / Allergic Colitis / PKU / gluten enteropathy / Phenylketonuria / Gastroesophageal Reflux / Protein Hydrolysate Elemental Formula Allergic Vomiting / /

Organization

American Academy / MAINE CENTER FOR DISEASE CONTROL / US Federal Reserve / /

/

Position

forward / nutritionist / /

Product

Thrive / Growth / /

ProvinceOrState

Maine / /

URL

http /

SocialTag