1. Georgia WIC Program State Ordered Formula: New Special Formula Order Form Training Presentation to: WIC Staff Presented by: Laura Iberkleid and Barbara Stahnke Date: December 2014

2. Objectives To review all sections of the new special formula order form To answer questions regarding the special formula order form and ordering process

3. The New Form

4. Phone (#1) – Previous Procedure Call when sending order – Current Procedure Email Laura Iberkleid, Barbara Stahnke, and Denali Lord when sending an order Fax (#2) – Send all faxes to this number Depending on your district policy and available tools, we can accept encrypted documents by e-mail. Special Formula Order Form

5. New Order (#3) – First order for participant – Change from old order form to new order form – ANY change to MDF Ounces/day Flavor Diagnosis Repeat Order (#4) – Nothing changed since previous month’s order – MDF has not expired – Continue to check repeat order after 3 months Special Formula Order Form

6. Rush Order (#5) – Check ‘yes’ if needed by next business day, otherwise check ‘no’ – Determined by district – Deadline of 3 pm to be processed the same day for next day delivery (Note: Not available for all products) Date Faxed (#6) SWO Notified (#7) – Notify via email – You will receive a reply within 24 hours Special Formula Order Form

7. MDF Reviewed and Attached (#8) – Make sure MDF is reviewed for accuracy before sending – MDF needs to be sent each month with order form Date of Next Cert Due (#9) – Enter date and month of next cert (including sub, mid, half) Next Cert Type (#10) – Select certification type M = Mid cert or Mid Assess (infant or woman) H = Half cert (child) S = Subsequent cert (child, woman) Special Formula Order Form

8. Name of WIC Participant & ID Number (#11) – Both needed Date of Birth (#12) – Verify this matches DOB on MDF form Child, Infant, Woman (#13) – Check appropriate line Special Formula Order Form

9. First Day to Use (#14) – Enter as month/day/year – Should be taken from the voucher printed – Can be entered at the time vouchers are printed in the issuance date column of your tracking form, or found in your vouchers printed history – You will need the voucher number and the “first day to use” each month for your order Special Formula Order Form

10. 1B 1C1D 1E 2E1A2B2C2D 3E 3D 4E4D 3C 3B 4B4C 2A 3A 4A

11. 2B2C3D 2E1C 1B1A 3E 3B 2A 3A3C 4D4E 4B4A4C 2D 1D 1E

12. Special Formula Order Form Voucher Code (#15) – 199 will always be the voucher code number for a State Ordered Formula Voucher Number (#16) – * NEW* Print up to 3 months at a time at certification or food package change – Voucher receipts are signed at issuance of the vouchers – Actual vouchers are given to the participant at the time of certification – Write in voucher number on order form instead of sending in voucher receipt – Tracking vouchers are signed at each pickup of formula

13. If Infant, Age as of first day of use date (#17) – Age in months/days – Infants only Feeding Type (#18) – FFF = Fully Formula Fed/Postpartum woman not breastfeeding – SBF = Some breastfed/Postpartum woman doing some breastfeeding – MBF = Mostly breastfed/Postpartum woman mostly breastfeeding Special Formula Order Form

14. Diagnosis(es) & ICD9/10 (#19) – Should justify the formula being ordered – Both diagnosis and ICD9/10 code recommended – Refer to Julianne’s presentation and Procedures Manual (FP 34-36) Name of Formula (#20) – Write in full name of formula – If more than one formula, fill out separate form for each formula – Example: ‘Neocate Junior’ or Neocate Infant’ Not ‘Neocate’ Special Formula Order Form

15. Flavor (#21) – If more than one flavor requested, fill out separate order form for each flavor – If no flavor options, enter n/a – If left blank, assumed to be unflavored Type of Formula (#22) – Check one or complete ‘other’ ‘Other’ can be packets, vials, etc. Special Formula Order Form

16. Justify RTF and/or Container Size (#23) (when other forms are available ) Justifications for FPIII & RTF Homelessness Unclean water Not able to prepare formula correctly Better compliance Better meets medical needs Justifications for Non- FPIII & RTF Homelessness Unclean water Not able to prepare formula correctly Justifications for Container Size 2 oz nursettes vs. larger RTF containers Cannot finish 32oz in 48 hours

17. Estimated Time on Formula (#24) – Most Restrictive Next certification Planned length of use on MDF Number of months until MDF expires Special Formula Order Form

18. Clinic Name, Contact Person, Phone Number (#25) – Direct phone number, if possible Ship Formula to (#26) – Include full shipping address and phone number of clinic that will be receiving the formula in case of delivery problem Print District Contact (#27) – Name and direct phone number Verified by (#28) – Include name, signature, direct phone number

19. Special Formula Order Form OR

20. New Order (#3) – First order for participant – Change from old order form to new order form – ANY change to MDF Ounces/day Flavor Diagnosis Repeat Order (#4) – Nothing changed since previous month’s order – MDF has not expired – Continue to check repeat order after 3 months Special Formula Order Form

21. NEW ORDERS (#29) a)# cans prescribed – Use prescribed oz/day on MDF form to calculate (oz/day) x 30 days = oz/month (oz/month) ÷ can size = # cans prescribed Use Common Formula Maximums to determine can size b) # cans allowed – Use Common Formula Maximums c)# cans on hand a)Prior formula on hand from this participant and/or formula received in your district from another participant**

22. Special Formula Order Form Find the Common Formula Maximums at http://dph.georgia.gov/wic-formula-resources

23. Special Formula Order Form ** # cans on hand ** All formula no longer being used by the participant it was ordered for should be placed in your formula on hand, and managed in your regular formula inventory.

24. Special Formula Order Form Total # cans needed (#30) – FFF Infants Receive the maximum number of cans allowed regardless of prescribed ounces on MDF – MBF Infants Maximum allowed is listed in procedures manual (FP Attachment 25) – Children and Women Receive ONLY what is prescribed on MDF Can round up to the next full can but may NEVER go over max

25. Special Formula Order Form Total # cans needed (#30) – Once number of cans needed to be issued for the month is determined: # Cans to be issued - # cans on hand = total # cans needed – Write in the total number of cans you need to receive from the State Office

26. Special Formula Order Form #31 - #33 – State WIC Office to Complete – Leave blank Additional Information (#34) – Any information that will be helpful in clarifying the order

27. Special Formula Order Form Repeat Orders (#35) – Check the month for the same MDF – Note: A revised or new MDF will be a New Order

28. Special Formula Order Form Repeat Orders (#36) a)# cans prescribed – Use prescribed oz/day on MDF form to calculate (oz/day) x 30 days = oz/month (oz/month) ÷ can size = # cans prescribed Use Common Formula Maximums to determine can size b) # cans allowed – Use Common Formula Maximums c)# cans on hand -(including formula in stock amounts)

29. Special Formula Order Form ** # cans on hand ** All formula no longer being used by the participant it was ordered for should be placed in your formula on hand, and managed in your regular formula inventory.

30. Special Formula Order Form Total # cans needed (#37) – FFF infant, MBF infant, Child, or Woman? – Once number of cans needed to be issued for the month is determined: # Cans to be issued - # cans on hand = total # cans needed – Write in the total number of cans you need to receive from the State Office

31. Special Formula Order Form #38 – State WIC Office to Complete – Leave blank Additional Information (#39) – Any information that will be helpful in clarifying the order

32. Special Formula Order Form Next Steps (#41) – Fax packing slip to SWO – No longer need to fax voucher receipt File with voucher receipts for that day – Signed voucher at formula pick-up *NEW* Keep the voucher in an easily accessible folder or box organized by participant and date.

33. Special Formula Order Tracking Form

34. Special Formula Order Form Trading Database (#42) Common Formula Maximums (#43)