How to Complete Form DMS-640: Arkansas Medicaid Therapy Prescription and Referral

Arkansas Form DMS-640 is the physician prescription and referral form used to authorize occupational therapy, physical therapy, and speech-language pathology for Medicaid-eligible children under age 21. The prescribing physician must complete the form personally to establish medical necessity, sign and date it, keep the original in the child’s medical record, and give a copy to the therapy provider.¹ The blank form is available as a Word document from the Arkansas Department of Human Services website.²

The form covers therapy under Arkansas Medicaid’s Child Health Services (EPSDT) program, including services delivered in a Developmental Day Treatment Center.³ It has been officially promulgated and cannot be modified in any way; any version with added fields, removed sections, or a reformatted layout will be rejected on Medicaid review.¹ Personal Care and Private Duty Nursing use separate forms, not the DMS-640.

Referral Box or Treatment Box

The top of the form has two checkboxes, and picking the right one depends on where the child is in the evaluation process.³

For an initial referral for evaluation only, check the referral box and leave the prescription block empty. Once the evaluation comes back and you decide therapy is needed, complete a separate DMS-640 with the treatment box checked.
For prescribing therapy after evaluation, check the treatment box and complete the prescription block with minutes per week and duration in months.
For renewing previously prescribed services, you may check both the referral and treatment boxes on a single form.

Checking both boxes on a brand-new patient, before evaluation results are in, is a common cause of rejection. When in doubt on a new patient, submit referral only and follow up with a separate prescription form.

Filling Out the Form

The prescribing physician must complete the DMS-640 personally. Forms filled in by office staff without direct physician involvement will not be accepted on review.¹

Patient name, entered exactly as it appears in Medicaid records.
Medicaid ID number. Mismatches between the name and ID number are one of the most common reasons forms get kicked back.⁴
Date of last physical examination, meaning the last time the prescribing physician personally saw the child. It can be a full physical, a routine check-up, or any office visit that involved direct evaluation.
Medical diagnosis establishing the need for therapy.
Developmental diagnosis, entered separately from the medical diagnosis.
Clinical indication for treatment: the results of the therapy evaluation that show why treatment is necessary. This field ties the diagnoses to the specific therapy being prescribed.
Prescription block: minutes per week and duration in months, if the treatment box is checked. Leave blank on a referral-only form.
Other information relevant to the child’s condition or plan of treatment.

Physician Identification

Enter the physician’s printed name and Arkansas Medicaid provider identification number, not the National Provider Identifier. Using the NPI instead of the Medicaid provider number stalls processing. If the prescribing physician is the child’s primary care physician, fill in the PCP block. If the child is exempt from PCP requirements, use the attending physician block and enter that physician’s provider identification number and/or taxonomy code.⁴

Signature and Date

The prescribing physician must sign and date the form in their original signature.¹ A signature without a date next to it invalidates the whole form.

Electronic signatures are allowed, but they must meet Arkansas Code 25-31-103. That statute requires the electronic signature to be unique to the person using it, capable of verification, under that person’s sole control, and linked to the document so that any change to the data invalidates the signature.⁵ If your EHR system cannot meet all four requirements, print the form and sign it by hand.⁴

Prescription Duration and Weekly Therapy Limits

A DMS-640 prescription is valid for whatever length the physician specifies, up to a one-year maximum. A renewed PCP referral is required at least every twelve months regardless of the prescription duration.⁶ Services delivered after the prescription expires, or without a current referral on file, are not reimbursable.

Arkansas Medicaid reimburses up to 90 minutes of therapy per discipline per week without prior authorization. Anything beyond that requires an extended therapy request. Weekly and annual limits by discipline:

Physical therapy: six units per week for individual and group therapy, two evaluation units per state fiscal year (July 1 through June 30).
Occupational therapy: six units per week, two evaluation units per state fiscal year.
Speech-language pathology: six units per week, four evaluation units per state fiscal year.

Extensions beyond these limits can be approved when medically necessary.⁶ Match what you enter in the prescription block to these limits, and request an extension separately if the child needs more.

Where to Submit

The preferred method is electronic submission through the Arkansas Medicaid Healthcare Provider Portal at portal.mmis.arkansas.gov.⁷⁸ AFMC handles utilization review under contract with Arkansas Medicaid. A registered nurse clinical services specialist screens the request first, and if the documentation supports medical necessity, that specialist may approve it. Anything that cannot be approved at that level goes to a physician advisor for a determination.

AFMC Clinical Services can also be reached by phone at 800-426-2234 during review hours, 8:00 a.m. to 12:00 p.m. and 1:00 p.m. to 4:00 p.m.

After submission, keep the original completed DMS-640 in the child’s medical record at the prescribing physician’s office. The therapy provider keeps a copy.¹

After You Submit

AFMC clinical reviewers compare the diagnoses and physician notes against Arkansas Medicaid coverage guidelines. If the documentation does not fully support medical necessity, AFMC may ask for additional information before deciding. Respond promptly; delay can lead to a formal denial.

If AFMC cannot fully approve the request, all applicable parties receive written notice of the determination and detailed instructions on how to appeal.⁷ Under the Medicaid Fairness Act, the recipient and the provider can each request a hearing to challenge a denial.⁹ Arkansas gives beneficiaries 30 days from the date of the adverse action notice to request a fair hearing through the DHS Appeals and Hearing Unit.¹⁰ When the denial looks like a documentation problem rather than a real medical-necessity dispute, resubmitting through the portal with additional clinical detail is often faster than a formal hearing.

Common Mistakes That Delay or Invalidate the Form

Most rejections come from a small set of avoidable errors:

Checking both boxes on an initial referral. Both boxes are only for renewals of previously prescribed services.
A signature without a date next to it, which invalidates the form.
Entering the NPI instead of the Arkansas Medicaid provider identification number.
Leaving the prescription block blank when the treatment box is checked. Minutes per week and duration in months are required.
Altering the form’s layout. The DMS-640 is promulgated and any modified version is rejected.
Staff completing the form without physician involvement. The physician must fill it in, not just sign it.
Billing services after the prescription end date or without a current PCP referral on file. Track expiration dates and start renewals early.

1
Arkansas Secretary of State. Instructions for Completion of Form DMS-640
2
Arkansas Department of Human Services. Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21
3
Cornell Law Institute. 016.06.04 Arkansas Code of Regulations 058
4
Arkansas Foundation for Medical Care. Arkansas Physician Medicaid Update Q3 SFY 2025
5
FindLaw. Arkansas Code Title 25 State Government 25-31-103
6
Arkansas Department of Human Services. Occupational, Physical, Speech Therapy Services – Effective Date 1-1-2021
7
AFMC. Medicaid Utilization Management Program
8
Arkansas Department of Human Services. Helpful Information for Providers
9
AFMC. Medicaid Review and Prior Authorization for Hospitals
10
Centers for Medicare and Medicaid Services. Medicaid Program Names and Appeals Contact Information