The Missouri WIC Form WIC-27 is the medical documentation form your healthcare provider completes when you or your child needs a formula or nutritional product that falls outside Missouri WIC’s standard food package. Without it, your local WIC clinic cannot issue any exempt infant formula, WIC-eligible nutritional, or non-contract formula brand.1Missouri Department of Health and Senior Services. Missouri WIC Medical Documentation – Health Care Provider Authorization Your provider fills it out, not you, but knowing what belongs on the form is the fastest way to avoid a rejection and a second trip to the office.
When You Need a WIC-27
Missouri WIC issues one of its contract Similac infant formulas by default.2Missouri Department of Health and Senior Services. Missouri WIC Approved Formulas and WIC-Eligible Nutritionals A WIC-27 is required any time you need something different: a non-contract formula, an exempt infant formula such as EleCare or Nutramigen, a WIC-eligible nutritional for an older child or adult, or even standard contract formula mixed differently than the label directs.1Missouri Department of Health and Senior Services. Missouri WIC Medical Documentation – Health Care Provider Authorization
Conditions That Qualify
The form lists specific qualifying conditions, each tied to a WIC Risk Factor code. Your provider selects from this list:
- Low birth weight under 2,500 grams, roughly 5 pounds 8 ounces (RF 141), applicable until 24 months of age
- Prematurity, birth before 37 weeks of gestation (RF 142), applicable until 24 months
- Metabolic disorders such as phenylketonuria (RF 351)
- Severe food allergies with documented reactions to standard formula ingredients (RF 353)
- Immune system disorders (RF 360)
- Gastrointestinal disorders including malabsorption syndromes (RF 342)
- Any other disorder, disease, or medical condition that could harm the participant’s nutritional status
For metabolic, immune, gastrointestinal, and allergy categories, the provider has to describe the specific disorder, not just check the box.1Missouri Department of Health and Senior Services. Missouri WIC Medical Documentation – Health Care Provider Authorization
What Will Not Qualify
Most denials come from this zone. The form warns that non-specific symptoms don’t qualify on their own: fussiness, gas, spitting up, constipation, colic, and general “intolerance” without an underlying diagnosed condition will be rejected. Requests aimed at boosting nutrient intake or managing body weight without a medical diagnosis behind them are also denied.1Missouri Department of Health and Senior Services. Missouri WIC Medical Documentation – Health Care Provider Authorization Requesting whole milk for women or children 24 months and older requires both medical documentation and a prescribed WIC formula; preference alone will not do it.
Where to Get the Form
The WIC-27 is a PDF download from the Missouri Department of Health and Senior Services website.1Missouri Department of Health and Senior Services. Missouri WIC Medical Documentation – Health Care Provider Authorization No substitute is accepted. Your provider’s office cannot use its own letterhead or a generic prescription pad in place of the WIC-27.3University Health WIC. Healthcare Providers If you don’t have internet access, any local WIC agency can hand you a paper copy. To find the nearest office, use the location map on the Missouri WIC homepage, call TEL-LINK at 1-800-835-5465, or fill out the online interest form to have an agency contact you.4Missouri Department of Health and Senior Services. Welcome to Missouri WIC
What Your Provider Must Include
Knowing each section helps you catch errors before the form leaves the office.
Participant Information
The participant’s full legal name and date of birth. The name has to match what the WIC clinic has on file. If there’s any variation, check the spelling with your clinic before the provider appointment.
Medical Reason and Diagnosis
Your provider picks the qualifying condition and enters the WIC Risk Factor code. Where the form asks the provider to describe the disorder or the allergy, a specific description is required. “GI issues” with no named condition gives the reviewer nothing to approve. Precision speeds the decision.
Formula or Nutritional Product Requested
This is the most detail-heavy part. Your provider must supply:
- The exact product name, such as “EleCare for Infants DHA/ARA” rather than “EleCare”
- The required calories per fluid ounce
- The daily amount in ounces or cans per day
- The approval length, from one to six months
Maximum approval length is six months for most exempt formulas and WIC-eligible nutritionals, but only two months for metabolic formulas.2Missouri Department of Health and Senior Services. Missouri WIC Approved Formulas and WIC-Eligible Nutritionals When that period ends, a new WIC-27 is needed if the formula is still required.
If the provider is prescribing a ready-to-use form instead of powder or concentrate, the form has a separate area to check the reason: either that ready-to-use better accommodates the participant’s condition, or that it improves compliance with the prescribed formula.1Missouri Department of Health and Senior Services. Missouri WIC Medical Documentation – Health Care Provider Authorization
Who Can Sign the Form
Missouri WIC accepts signatures only from a limited set of prescribing providers:
- Medical doctors (MD)
- Doctors of osteopathy (DO)
- Physician assistants supervised by a medical doctor
- Nurse practitioners or certified clinical nurse specialists with a physician agreement based on standards from the Missouri Nurses Association and Missouri Medical Association
Credentials and contact information need to be legible, because WIC staff may call the office to verify.5Missouri Department of Health and Senior Services. Who Can Complete a Medical Documentation Form (WIC-27)? A registered dietitian, pharmacist, or medical assistant cannot sign, even if that person knows the patient’s nutrition best. When a specialist’s office has no eligible prescriber on hand, the primary care physician can complete the form based on the specialist’s recommendations.
Submitting the Completed Form
The signed WIC-27 goes to your local WIC clinic, not to a state office. You have three practical options:
- Fax from the provider’s office directly to the clinic. This is usually the fastest route; your clinic can give you the fax number.
- Hand delivery at your next WIC appointment or a drop-off at the clinic.
- Telephone documentation. Federal regulations let a provider call the information in to a competent professional authority at the clinic, with a signed copy to follow. Use this when timing is urgent and a baby needs formula now.6eCFR. 7 CFR 246.10 – Supplemental Foods
The clinic keeps the documentation on file, either as hard copy or electronically.6eCFR. 7 CFR 246.10 – Supplemental Foods
After You Submit
A WIC nutritionist or competent professional authority at the clinic reviews the form and marks approval or disapproval in a dedicated section. If anything is unclear or incomplete, the reviewer contacts the provider’s office before deciding.1Missouri Department of Health and Senior Services. Missouri WIC Medical Documentation – Health Care Provider Authorization Once approved, the product is added to your eWIC card so you can buy it at authorized retailers.
Forms most often come back for a missing or vague diagnosis description, a non-qualifying condition listed as the sole justification, an incomplete product name, or a missing signature. Getting those right the first time keeps you from making a round trip back to your provider.
If Your Request Is Denied
A denial is not the end. You have the right to request a fair hearing within 60 calendar days. Start by contacting your local WIC agency, or reach the Missouri WIC program at P.O. Box 570, Jefferson City, MO 65102, or 800-392-8209.7University Health WIC. WIC-10 – Rights and Responsibilities Before filing for a hearing, ask your provider to look at the form again. Many denials trace back to documentation gaps rather than real disagreement about medical need, and a corrected resubmission is faster than an appeal.