Arkansas Division of Medical Services

1
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.
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Office Email
example@example.com
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Referral (Check all that apply)
OT
PT
ST
Treatment
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Patient Name
First Name
Last Name
5
Patient Medicaid ID#
6
Date child was last seen in office:
Date
Year
Month
Day
7
Diagnosis as Related to Prescribed Therapy:
Huge
Large
Normal
Small
Ok
Ok
8
Complete this block if this form is a prescription
Minutes/week
Duration in months
Not medically necessary
Notes
OT
15
30
45
60
75
90
105
120
135
150
165
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195
210
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255
270
285
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400
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
PT
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
240
255
270
285
300
315
330
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360
375
400
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
ST
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
240
255
270
285
300
315
330
345
360
375
400
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
OT
PT
ST
Minutes/week
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
240
255
270
285
300
315
330
345
360
375
400
Row 0, Column 0
Duration in months
Row 0, Column 1
Not medically necessary
Row 0, Column 2
Notes
Row 0, Column 3
Minutes/week
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
240
255
270
285
300
315
330
345
360
375
400
Row 1, Column 0
Duration in months
Row 1, Column 1
Not medically necessary
Row 1, Column 2
Notes
Row 1, Column 3
Minutes/week
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
240
255
270
285
300
315
330
345
360
375
400
Row 2, Column 0
Duration in months
Row 2, Column 1
Not medically necessary
Row 2, Column 2
Notes
Row 2, Column 3
1 of 3
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Image Field
10
Primary Care Physician (PCP) Name
First Name
Last Name
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PCP Provider ID Number/Taxonomy Code
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Attending Physician Name
First Name
Last Name
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Attending Physician Provider ID Number/Taxonomy Code
14
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.
Clear
Should be Empty: