016 05 18 Ark Code R 003 - Summary of the Occupational 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by checking the appropriate boxes for the therapy modalities being referred: Occupational Therapy (OT), Physical Therapy (PT), or Speech Therapy (ST).
  3. Enter the patient's full name and Medicaid ID number in the designated fields.
  4. Fill in the date when the child was last seen in your office, ensuring accuracy for compliance.
  5. Provide a diagnosis related to the prescribed therapy, clearly indicating medical necessity.
  6. If this form is a prescription, specify the number of minutes per week and duration in months for each type of therapy required.
  7. Complete the Primary Care Physician (PCP) and Attending Physician sections with names and provider identification numbers.
  8. 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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