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Arkansas Medicaid DMS-0843 Wheelchair Evaluation

Arkansas Medicaid requires the DMS-0843 when a beneficiary needs a wheelchair or wheelchair seating, which the general equipment form does not cover. Three parties complete separate parts: the DME provider, the assistive technology professional (ATP) and the prescribing physician or APRN. The DME provider submits the finished evaluation with its prior authorization request.

Who completes it

The DME provider completes Part A (client, home access, transport and current chair) and the ATP completes Part B (specifications, measurements, positioning and medical necessity). The prescribing physician or APRN completes Part C with medications, diagnosis, injury details, planned surgery, other equipment and seizure control, then signs.

Submitting and payment

How to submit it
The DME provider submits the completed DMS-0843 with its prior authorization request to Arkansas Medicaid.
Who pays
The form sets no fee for the prescriber; it supports the DME provider's prior authorization for the wheelchair.

Good to know

  • Part C must carry the prescriber's own signature: the form says no stamp. It also asks for the provider number and the date of evaluation.
  • The form directs a PT, OT or seating specialist to complete Part B only for a scooter or a Group 1 or Group 2 power wheelchair with no power options.
  • Part B signers list whether they are RESNA certified and give the certification number, and every option such as drive controls or tilt needs a written justification.
  • Other medical equipment goes on DMS-679, which excludes wheelchairs and wheelchair components. DMS-0843 is a Word document, revised 9/1/18.

Get the official form

Download the current version from the source each time; forms change without notice.

Evaluation for Wheelchair and Wheelchair Seating

Official pageWord file

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How this list is checked

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Frequently asked questions

What does the physician complete on Arkansas form DMS-0843?

The prescribing physician or APRN completes Part C only: current medications, diagnosis, injury and date and level of injury, whether surgery is planned, other equipment such as oxygen, a ventilator or a communication device, and whether seizures are controlled. They print their name and provider number, sign without a stamp and date the evaluation.

Is DMS-0843 used for all Arkansas Medicaid DME?

No. DMS-0843 is specific to wheelchairs and wheelchair seating. Other durable medical equipment is requested on DMS-679, the Prescription and Prior Authorization Request for Medical Equipment, whose title states that it excludes wheelchairs and wheelchair components.