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016 05 18 Ark Code R 003 - Summary of the Occupational 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by checking the appropriate boxes for the therapy modalities being referred: Occupational Therapy (OT), Physical Therapy (PT), or Speech Therapy (ST).
- Enter the patient's full name and Medicaid ID number in the designated fields.
- Fill in the date when the child was last seen in your office, ensuring accuracy for compliance.
- Provide a diagnosis related to the prescribed therapy, clearly indicating medical necessity.
- If this form is a prescription, specify the number of minutes per week and duration in months for each type of therapy required.
- Complete the Primary Care Physician (PCP) and Attending Physician sections with names and provider identification numbers.
- Finally, ensure that you sign and date the form as required, adhering to Arkansas Medicaid’s electronic signature criteria if applicable.
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medicaid dms 640 form
The following Rules and Regulations for Hospitals and Related Institutions in Arkansas are duly adopted and promulgated by the Arkansas State Board of HealthRead more
1. A written referral for occupational therapy, physical therapy or speech-language pathology services is required from the patients primary care physician (Read more