Dms 640 2026

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Click ‘Get Form’ to open the DMS-640 in the editor.
Begin by entering the patient's full name in the 'Patient Name' field.
Input the patient's Medicaid ID number in the designated field.
Fill in the 'Date Child Was Last Seen In Office' with the most recent visit date.
Provide the primary diagnosis description or ICD-9 code in the 'Primary Diagnosis' section.
In 'Diagnosis as Related to Prescribed Treatment', specify the diagnosis that justifies therapy necessity.
If prescribing therapy, check the appropriate treatment box and enter prescribed minutes per week and duration in months.
If therapy is not medically necessary, check that box accordingly.
Complete any additional information relevant to treatment in 'Other Information'.
Print and fill out your name and provider ID under 'Primary Care Physician (PCP) Name'.
If applicable, print and fill out attending physician details along with their provider ID.
Finally, sign and date the form to certify its accuracy before submission.

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Versions	Form popularity	Fillable & printable
2016	4.9 Satisfied (51 Votes)
2009	4 Satisfied (40 Votes)

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