016.06.04 Ark. Code R. § 058 - Official Notice DMS-2004-AR-3, DMS-2004-C-5, DMS-2004-F-3, DMS-2004-I-2, DMS-2004-L-6, DMS-2004-KK-5, DMS-2004-FF-3, DMS-2004-R-6, DMS-2004-EE-2, DMS-2004-Y-4, DMS-2004-YY-6, and revised form DMS-640

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Instructions for Completion

Form DMS-640 - Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21 PRESCRIPTION/REFERRAL

* If DMS-640 is used to make an initial referral for evaluation, check the referral box only. After receiving the evaluation results and determining that therapy is necessary, you must use a separate DMS-640 form to prescribe the therapy. Check the treatment box for prescription and complete the form following the instructions below. If the referral and prescription are for previously prescribed services, you may check both boxes.

* Patient Name - Enter the patient's full name.

* Medicaid ID # - Enter the patient's Medicaid ID number.

Physician/Physician's office staff must complete the following:

* Date Child Was Last Seen In Office - Enter the date of the last time you saw this child. (This could be either for a complete physical examination, a routine check-up or an office visit for other reasons requiring your personal attention.)

* Primary Diagnosis - Enter the primary medical diagnosis description or ICD-9 diagnosis code.

* Diagnosis as Related to Prescribed Treatment - Enter the diagnosis that indicates or establishes medical necessity for prescribed therapy.

* Prescription block - If the form is used for a prescription, enter the prescribed number of minutes per week and the prescribed duration (in months) of therapy.

* If therapy is not medically necessary at this time, check the box.

* Other Information - Any other information pertinent to the child's medical condition, plan of treatment, etc., may be entered.

* Primary Care Physician Name and Medicaid Provider Number - Print the name of the prescribing primary care physician and his or her Medicaid provider number.

* Attending Physician Name and Medicaid Provider Number - If the Medicaid-eligible child is exempt from PCP requirements, print the name of the prescribing attending physician and his or her Medicaid provider number.

* Physician Signature and Date - The prescribing physician must sign and date the prescription for therapy in his or her original signature.

*These therapy amounts include therapy provided in a Developmental Day Treatment Center (DDTCS)

The original of the completed form DMS-640 must be maintained in the child's medical records by the prescribing physician. A copy of the completed form DMS-640 must be retained by the therapy provider.

Notes

016.06.04 Ark. Code R. § 058

10/11/2004