• DSHS HIV/STD Program
    Post Office Box 149347, MC 1873
    Austin, TX 78714

    Phone: 737-255-4300

    Email the HIV/STD Program

    Email HIV, STD, Hepatitis C, and TB data requests to the Program – Use this email to request Texas HIV, STD, Hepatitis C, and TB data and statistics. Do not use this email to request treatment or infection history for individuals, or to request information on programs or services. Do not email personal, identifying health information such as HIV status, date of birth, or Social Security Number.

    For treatment/testing history, please contact your local health department.

    For information on HIV testing and services available to persons living with HIV, please contact your local HIV services organization.

Texas HIV Medication Program – Medical Certification Form Quick Facts


THMP receives and processes numerous MCFs for our clients every day.

Below is a quick reference for some of the most frequently asked questions about MCFs. (Medical Certification Form Quick Facts print version (PDF))


How can my client receive a 90-day prescription?

A 90-day supply is available for a limited number of medications and as an exception to the normal dosing schedule, for example as a vacation supply.


What other important information do I need to know about MCFs?

  • MCFs must be signed by a physician, physician’s assistant, or nurse practitioner.
  • When a client’s medication regimen changes a new MCF must be submitted to THMP with the complete regimen selected.
  • MCFs have a four (4) anti-retroviral (ARV) drug limit – some drug “boosters” are allowable as a fifth drug (see Formulary (PDF)).
  • THMP Pharmacy Coordinator must approve medication requests that exceed five (5) drugs or unusual combinations. A letter from the provider must be included justifying the request.
  • High dosages require a signed letter of justification from the provider. Please refer to the THMP Medication Formulary and Maximum Quantities Table (PDF) for available mediations/dosages.
  • MCFs with a new request for Selzentry must include a copy of Trofile/CCR5 test.
  • THMP will provide the generic equivalent of prescribed medication when available- refills may be different generic equivalents depending on inventory at the time of each refill.
  • Address and pharmacy changes may not be requested on MCF.


What if my client is prescribed Hepatitis C medications or Trogarzo?

Hepatitis C medication pilot is currently suspended. Please see the Trogarzo MCF (PDF).


How do I submit an MCF to THMP?

  • For new applicants, the MCF should be included with the THMP application. In the Take Charge Texas (TCT) portal, the MCF can be scanned in as a proof of positivity document.
  • Always fax a MCF for medication changes to THMP at 512-989-4003.
  • NEVER email a MCF or any information that has identifying/personal health information.


What do I need to check before submitting an MCF?

  • All client information must be completely filled out.
  • Lab values are requested but are not required if client is new and does not have labs completed.
  • Each medication requested is checked on MCF.
  • All physician/provider information must be filled out.
  • MCF includes physician/provider’s signature.


 


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Last updated March 24, 2022