ࡱ> knja 0Zbjbj:K:K ebX!H\X!H\  $P|tt5.>#%&l:4<4<4<4<4<4<4$I79 `4u$'""@$'$'`4h4z,z,z,$'L:4z,$':4z,z,:j1,1p'1 &44051R ;'b ;1 ;14$'$'z,$'$'$'$'$'`4`4)$'$'$'5$'$'$'$' ;$'$'$'$'$'$'$'$'$' > J: Arkansas Division of Medical Services Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 PRESCRIPTION/REFERRAL The Primary Care Physician (PCP) or attending physician must use this form to make a referral for evaluation or prescribe medically necessary Medicaid therapy services. The PCP or attending physician must check the appropriate box or boxes indicating the modality. Providers of therapy services are responsible for obtaining renewed PCP referrals every 6 months in compliance with Section I 171.400 and Section II 214.00 of the Arkansas Medicaid Therapy services provider manual. Referral (check all that apply)  FORMCHECKBOX  OT  FORMCHECKBOX  PT  FORMCHECKBOX  ST  FORMCHECKBOX  Treatment EVALUATE/TREAT IS NOT A VALID PRESCRIPTION Patient Name:  FORMTEXT       Medicaid ID #:  FORMTEXT       Date Child Was Last Seen In Office:  FORMTEXT       Diagnosis as Related to Prescribed Therapy:  FORMTEXT       ______________________________________________________________________________________________ Complete this block if this form is a prescriptionOccupational Therapy (OT)Physical Therapy (PT)Speech Therapy (ST) FORMTEXT      Minutes per week FORMTEXT      Minutes per week FORMTEXT      Minutes per week FORMTEXT      Duration (months) FORMTEXT      Duration (months) FORMTEXT      Duration (months) FORMCHECKBOX  Therapy Not Medically Necessary  FORMCHECKBOX  Therapy Not Medically Necessary  FORMCHECKBOX Therapy Not Medically Necessary Other Information:  FORMTEXT       Note: FORMTEXT       OTPTSTExpenditures for SFY15*$46,259,404*$35,025,080*$70,442,268Average Units Per Beneficiary949497Average Cost Per Beneficiary$1,930$1,892$1,945Total Beneficiaries Served23,95718,50536,217  FORMTEXT        FORMTEXT       Primary Care Physician (PCP) Name (Please Print) Provider ID Number/Taxonomy Code  FORMTEXT        FORMTEXT       Attending Physician Name (Please Print) Provider ID Number/Taxonomy Code By signing as the PCP or Attending Physician, I hereby certify that I have carefully reviewed each element of the therapy treatment plan, that the goals are reasonable and appropriate for this patient, and in the event that this prescription is for a continuing plan I have reviewed the patients progress and adjusted the plan for his or her meeting or failure to meet the plan goals.  FORMTEXT        FORMTEXT       Physician Signature (PCP or attending Physician) Date Return To (name of provider): FORMTEXT       DMS-640 (Rev. 6/16) Instructions for Completion Form DMS-640  Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 PRESCRIPTION/REFERRAL If DMS-640 is used to make an initial referral for evaluation, check the box to indicate the appropriate therapy for the referral. 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 patients full name. Medicaid ID # Enter the patients Medicaid ID number. Return To To be completed by requesting provider to include therapy provider/address/fax/secure email. Physician or Physicians 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.) Diagnosis as Related to Prescribed Therapy 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. 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Primary Care Physician (PCP) Name and Provider ID Number and/or Taxonomy Code Print the name of the prescribing PCP and his or her provider identification number and/or taxonomy code. Attending Physician Name and Provider ID Number and/or Taxonomy Code If the Medicaid-eligible child is exempt from PCP requirements, print the name of the prescribing attending physician and his or her provider identification number and/or taxonomy code. Physician Signature and Date The prescribing physician must sign and date the prescription for therapy in his or her original signature. Arkansas Medicaids criteria for electronic signatures as stated in Arkansas Code 25-31-103 must be met. For vendors EHR systems that are not configurable to meet the signature criteria, the provider should print, date and sign the DMS-640 form. Providers will be in compliance if a scanned copy of the original document is kept in a format that can be retrieved for a specific beneficiary. Most electronic health record systems allow this type of functionality. When an electronic version of the DMS 640 becomes part of the physician/ or providers electronic health record, the inclusion of extraneous patient and clinic information does not alter the form. *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 childs medical records by the prescribing physician. A copy of the completed form DMS-640 must be retained by the therapy provider.       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