Texas WIC issues its contract formulas without paperwork, but a therapeutic formula, or any formula for a child over age 1, needs this medical request. The prescriber records growth data, the formula and daily amount, the length prescribed, the qualifying condition and any food changes. Local WIC clinical staff review every request against state WIC policy and federal regulations before approving it.
The prescriber, checking MD, DO, NP or PA-C, completes sections 1 through 7 (section 2 is optional) and signs or stamps section 7 with an individual NPI and facility name. The bottom line is reserved for the WIC clinic.
Enter the patient's name, date of birth and guardian's name, then the date of measurements with current height and weight. Weeks gestation and birth weight are asked for every patient, and they back up a prematurity or low birth weight condition checked in section 5. The date of measurements shows WIC staff when the height and weight were taken.
Check breast pump, breastfeeding support or latch assistance if the parent would benefit from help from the WIC clinic. The section is optional, and WIC clinic staff can follow up on the support you check. The form also points families to the Texas Lactation Support Hotline, which offers IBCLC help around the clock.
Write the formula name and either cans per day or ounces per day. WIC may provide the maximum allowed unless a lesser amount is indicated or the formula supplements breastfeeding, so write a lower amount when that is what you intend. Check the Texas WIC formulary first: the program does not provide products such as Enfamil Enspire, NeuroPro powder, A2, Organic or ProSobee.
Check 3 Months, 6 Months or 12 Months, or enter a different period on the Other line. The length you mark is how long you are prescribing the formula, and WIC clinical staff review it together with the rest of the request against state WIC policy and federal regulations before the product is issued.
Check every condition that applies: cardiovascular, impaired digestion or absorption, developmental delays, inadequate growth, food allergies (cow's milk, soy or intact protein) or FPIES, oral motor feeding issues, FTT, prematurity or LBW, GER/GERD, GI disorder, renal disease or low mineral condition, respiratory condition, or tube feeding. Use the other line to describe any other medical condition. Formula cannot be provided to manage body weight without an underlying condition.
The WIC RD or nutritionist sets the food package unless you mark otherwise. For infants 6 to 11 months, check infant cereal or baby foods to remove, or formula only. For children 12 months and older and women, check foods to remove (milk, yogurt, eggs, juice, peanut butter, cheese, whole grains, cereal, beans, fruits and vegetables), choose formula only, or request baby foods and infant cereal when a child cannot yet manage solids.
Sign or stamp the form, date it, and check MD, DO, NP or PA-C. Print your name and give your individual NPI, phone, fax and facility name. The For WIC Use Only line beneath, with the clinic's name and contact details, is completed by WIC, not by the prescriber.
Download the current version from the source each time; forms change without notice.
Texas WIC Medical Request for Therapeutic Formula
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Yes. The form states that all formula requests for children over age 1 require a medical request, even for a product infants can get without one. Use section 3 for the formula and amount, section 4 for 3, 6 or 12 months or another length, and section 5 for the qualifying condition.
Section 7 has checkboxes for MD, DO, NP and PA-C. The prescriber signs or stamps the form, dates it, prints their name, and adds an individual NPI, phone, fax and facility name. Metabolic formula requests are different: they go on form EF13-06-13158 and must come from a recognized metabolic center.
No. Section 5 states that formula cannot be provided to manage body weight without an underlying condition. Check one of the listed conditions, such as prematurity or low birth weight, FTT, inadequate growth, food allergy or FPIES, or tube feeding, or describe another medical condition in the space provided.
Texas WIC posts its formulary, most recently the July 2025 version, on the Formula Prescriptions page for health partners, next to this form and the metabolic formula request. The page notes that product details can change and suggests confirming them with the manufacturer.