How to Complete and Submit the Virginia WIC-395 Form: Special Prescription

The Virginia WIC-395 form is the Request for Special Prescription that a licensed healthcare provider completes to authorize a specialized formula or modified food package for a participant in the state’s Women, Infants, and Children program. Every field has to be filled in, the provider has to sign it by hand, and it goes to the participant’s local WIC clinic by fax or in person. Incomplete forms are sent back.¹

When You Need to Submit One

Virginia WIC’s infant formula contract is with Abbott. Four Similac products are available to infants with no medical paperwork at all: Similac Advance, Similac Sensitive, Similac Total Comfort, and Similac Soy Isomil. If one of those works, no WIC-395 is needed.¹

Medical documentation, preferably on the WIC-395, is required whenever a provider prescribes:

a non-contract infant formula (any infant formula other than the four standard Similac options above, including Similac for Spit-Up);
an exempt infant formula for a metabolic, gastrointestinal, or other serious condition (products such as EleCare, Neocate, or Nutramigen); or
a WIC-eligible nutritional for a child or woman, such as Boost, Ensure, PediaSure, Kate Farms products, Duocal, or Benecalorie.

Federal regulations require documentation for all three categories.² Products that are not on the Virginia WIC Approved Formulary cannot be provided no matter what the form says. That list of ineligible products includes all Enfamil and Gerber routine infant formulas, generic and store-brand formulas, and certain Similac specialty sizes.¹

Conditions That Will Not Qualify

Virginia WIC will deny a WIC-395 if the sole diagnosis is one of the conditions it has specifically ruled out: colic, eczema, constipation, diarrhea, gas, fussiness, weight loss, slow or poor weight gain, non-specific feeding difficulties, spitting up, vomiting, non-specific formula intolerance or allergy, picky eating, or a general request to boost nutrient intake or manage body weight. Food intolerances or allergies that can be managed with regular foods also don’t qualify.³

The qualifying standard is a diagnosed medical condition that severely impairs how the body takes in, digests, absorbs, or uses nutrients, to the point that routine foods or standard formulas cannot meet the participant’s needs. The diagnosis has to be consistent with the formula being requested, and an ICD diagnostic code is required.³

Filling Out the Form

The WIC-395 is three pages, one each for infants, children, and women. Use the page that matches the participant’s category; submitting the wrong page causes delays. The current version is available on the Virginia Department of Health’s healthcare providers page.³

Section A: Patient Information

For infants and children, enter the participant’s name and date of birth, the parent or guardian’s name, a phone number, and whether the participant currently has Virginia Medicaid. For women, enter the participant’s name, date of birth, and either the estimated due date or the end date of the most recent pregnancy.³

Section B: Formula Information

This is the heart of the form. If more than one product is being prescribed, list them all on a single WIC-395 rather than submitting separate forms. For each formula, provide:

the exact product name as it appears on the Virginia WIC Approved Formulary;
the amount per day, either the standard WIC amount or a specific number of ounces;
calories per ounce, either standard dilution or a specific concentration;
length of use, anywhere from one to six months; and
the diagnosis with its ICD code.

The infant page has one additional question: whether ready-to-feed formula is medically required. If yes, the provider has to write a justification for why powdered or concentrated versions won’t work.³

Section C: Supplemental Foods

WIC participants normally receive a food package along with any prescribed formula. Section C is where the provider says whether that package should be modified for this participant. Infant options include no restrictions (or infant under six months), delaying WIC foods until a specified age, or removing infant cereal or pureed fruits and vegetables. For children and women, the choices range from no restrictions, to formula only with all other WIC foods removed, to removing or modifying specific items such as milk, yogurt, cheese, juice, cereal, beans, whole grains, eggs, fruits and vegetables, peanut butter, or (for women) canned fish. If the participant tolerates the standard package, select “no restrictions.”³

Provider Information and Signature

The last section (D on the infant and child forms, E on the woman form) is for the prescribing provider: printed name, NPI number, clinic name, phone, fax, date, and an original handwritten signature. The form must be completed and signed by a healthcare provider licensed to write prescriptions under state law.⁴

Where to Send It

Send the completed form, by fax or in person, to the participant’s local WIC clinic. The Virginia Department of Health posts a directory of clinic locations and contact information on its website.⁵ The WIC-395 is preferred, but Virginia WIC will accept documentation in other written forms, including on a standard prescription pad, as long as it contains all of the same information and carries the prescriber’s original signature.¹

After You Submit

WIC staff check the form for completeness and confirm that the diagnosis supports the formula requested. If anything is missing, they’ll contact the prescriber and ask for a new submission. They cannot take a verbal order or verbal clarification to patch a gap.¹

Missing fields are the most common reason forms come back. A vague diagnosis or one on the non-qualifying list will produce a denial. The form’s instructions ask providers to include as much detail about the diagnosis as possible to help avoid delays, so if medical necessity might be questioned, add clinical context in the diagnosis field rather than relying on the ICD code by itself.³

Renewing the Prescription

A WIC-395 is not permanent. Virginia WIC requires medical documentation to be updated at least every six months, and the documentation is valid only for a single WIC certification period. When the participant is recertified, a new WIC-395 or equivalent documentation has to be submitted even if the condition hasn’t changed.¹ Six months is also the maximum length of use allowed in Section B, so participants on long-term specialty formulas need their provider to resubmit on a regular cycle.

1
Virginia Department of Health. Healthcare Providers – Women, Infants and Children
2
eCFR. 7 CFR 246.10 – Supplemental Foods
3
Virginia Department of Health. Virginia WIC-395 Form
4
Virginia Department of Health. Virginia WIC-395 FormHealthcare Providers – Women, Infants and Children
5
Virginia Department of Health. Local Health District Map