The 17 Arkansas forms that ask for a clinician's input, from Medicaid prior authorization and therapy referrals to medical marijuana certification and the AR-3 report.
This page lists the 17 Arkansas forms that ask for a clinician's input, grouped by program. Most are Medicaid forms: the Prescription Drug Program Statement of Medical Necessity for drug prior authorization, the DMS-640 therapy prescription for beneficiaries under 21, and the DMS-679 prescription and prior authorization request for medical equipment. On workers' comp claims the treating physician files the AR-3 Physician's Report. The 10-336 certifies a patient for a disability license plate or placard.
Several Medicaid forms, including the DMS-640, DMS-679 and DMS-0843, are Word documents rather than PDFs, and the DMS-679 and DMS-0843 don't accept signature stamps. A narrative medical report may take the place of the AR-3. The medical marijuana certification must come from an Arkansas MD or DO with a DEA registration, and the patient submits it within 30 days of your signature. The Arkansas POLST also comes in Spanish. Vero Documents fills PDF forms from the visit note and the chart, and you review and sign.
Treating physician's first, progress or final report of the injury, diagnosis, treatment, prognosis and date of release from treatment for an Arkansas workers' compensation claim.
Certifies that a patient is permanently or temporarily disabled (conditions A-L) for a disability license plate or parking certificate (placard).
General prescription drug prior authorization/statement of medical necessity request for Arkansas Medicaid fee-for-service beneficiaries.
PCP or attending physician referral for evaluation or prescription of medically necessary OT/PT/speech therapy for Medicaid beneficiaries under 21.
Combined prescription and prior authorization request for Medicaid durable medical equipment (excluding wheelchairs and wheelchair components).
Seating and mobility evaluation and prescription supporting prior authorization of wheelchairs and wheelchair seating.
Medical need (level of care) assessment for nursing facility, ICF/ID, PACE, TEFRA and DAAS waiver programs.
PCP prescription/referral for medically necessary EPSDT services or items for beneficiaries under 21 that are not otherwise covered in the State Plan.
Physical examination and clearance portion of the AAA pre-participation physical required for Arkansas interscholastic athletics.
Annual application for a medical, religious or philosophical exemption from child care/school immunization requirements; medical requests must include a physician statement reviewed by the Immunization Section Medical Director.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Portable physician order documenting resuscitation, medical interventions and artificial nutrition preferences for seriously ill patients under the Arkansas POLST Act (2017).
Physician certifies that the patient has a qualifying medical condition (and whether a minor or physically disabled for caregiver eligibility) so ADH can issue a registry ID card.
Online submission of a child maltreatment report to the Arkansas Child Abuse Hotline by a mandated reporter.
Reports a case of a mandatory reportable communicable disease or condition to the Arkansas Department of Health, with hepatitis, tickborne and influenza sections.
Reports a bite by a mammal, which Arkansas law requires to be reported immediately for rabies assessment.
Physician, psychologist or psychological examiner certifies a dependent's diagnosis of a developmental disability (autism, cerebral palsy, Down syndrome, epilepsy, intellectual disability) originating before age 22 so the taxpayer can claim the Arkansas developmental disabilities credit.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. The AWCC requires Form 3 or a narrative medical report for every compensable case. The AR-3 Physician's Report has checkboxes for first, progress and final reports and covers the injury, diagnosis, treatment, prognosis and date of release from treatment. The treating physician sends it to the insurance carrier, self-insured employer or TPA. The authority is Ark. Code Ann. 11-9-516 and AWCC Rule 27.
A licensed physician, physician assistant, physical therapist or advanced practice registered nurse completes Part 1 of Form 10-336, checking the qualifying conditions A through L. Part 2 is for transport organizations. The applicant presents the form at a state Revenue Office. A temporary certificate expires 3 months after issue, and a permanent one can be renewed without recertification.
An Arkansas-licensed MD or DO with a DEA registration. The physician completes the Physician Written Certification page of the patient application packet, choosing from the printed qualifying conditions, since handwritten conditions are not accepted, and noting whether the patient is a minor or physically disabled. The patient submits it to ADH online or by mail within 30 days of the physician's signature. Every renewal needs a new form, and re-certification assessments may be done by telehealth.
When a Medicaid beneficiary under 21 needs occupational, physical or speech therapy. The primary care or attending physician completes the prescription or referral for evaluation or therapy, with therapy type, diagnosis and frequency, and signs it with an original or qualifying electronic signature. It goes to the therapy provider and stays in the record, supporting therapy prior authorization and retrospective review. It is renewed each prescription period.