Texas WIC uses this one-page request for participants with an inborn error of metabolism who need a metabolic formula or medical food. It records the qualifying diagnosis and measurements, the formula with amount per day, unit size and units per month, the issuance length, and any changes to infant or child foods. It also names the patient's metabolic center and nutritionist, and local WIC clinical staff review every request.
The prescribing provider (MD, DO, PA or NP) completes sections A to C, adding the metabolic nutritionist, metabolic center, contact frequency and an individual NPI, and signs or stamps it. WIC enters its local agency number.
Download the current version from the source each time; forms change without notice.
Texas WIC Medical Request for Metabolic Formula
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A health care provider marked MD, DO, PA or NP signs or stamps it, with a printed name, phone, date, individual NPI and fax. The same section names the metabolic nutritionist and metabolic center caring for the patient and how often they are in contact.
Yes, if the provider asks. The children's food section has an option to provide milk in addition to formula, plus options to issue medical formula only, omit specific foods such as eggs, cheese or peanut butter, or provide baby foods when the child can't eat table foods.
The metabolic request, EF13-06-13158, is for metabolic formulas and foods and asks for the patient's metabolic center and nutritionist. Other medically indicated formulas go on the Texas WIC Medical Request for Therapeutic Formula, F13-06-13152. Both are posted on the Texas WIC formula prescriptions page.