Letters of Medical Necessity & Detailed Written Order Templates

***The following have been drafted for healthcare professionals (i.e. dietitian or physician) to complete. These templates can be customized to fit the patient’s individual needs.  Please note that these resources do not guarantee insurance coverage or reimbursement of medical foods.***

Detailed Written Order Template

Detailed Written Order Template

Letters of Medical Necessity

Single Dose Amino Acids



EAA Supplement

FruitiVits (Ketogenics)

FruitiVits (Inborn Errors of Metabolism)

GA Express15

GA Gel


HCU cooler15

HCU express15

HCU express20

HCU gel


MCT Procal

MMA-PA cooler15 (MMA)

MMA-PA cooler15 (PA)

MMA-PA express15

MMA-PA gel

MSUD cooler15

MSUD express15

MSUD express20

MSUD gel

PKU coolers

PKU express15

PKU express20

PKU gel



TYR cooler15

TYR express15

TYR express20

TYR gel

UCD trio

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Carbzero, Fruitivits, Keyo, Vitabites and SOS are not eligible for Formula4Success.