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Arkansas DMS-640: Therapy Prescription Under 21

Arkansas Medicaid requires the DMS-640 before a child under 21 can receive occupational, physical or speech therapy. The primary care physician or attending physician uses one form to refer for evaluation and, after reviewing the results, a separate form to prescribe minutes per week and duration. Therapy providers must obtain a renewed PCP referral every six months.

Who completes it

The PCP, or the attending physician when the child is exempt from PCP requirements, completes and signs the form. The requesting therapy provider fills in the Return To field with its name and contact details.

Submitting and payment

How to submit it
Return the signed form to the therapy provider named in the Return To field. The prescribing physician keeps the original in the child's medical record, and the therapy provider keeps a copy.
Who pays
The form sets no fee for the physician; it supports the therapy provider's services under Arkansas Medicaid.

Good to know

  • "Evaluate and treat" is not a valid prescription. A referral for evaluation and the prescription that follows must be on separate forms, unless both are for previously prescribed services.
  • For each therapy prescribed, enter minutes per week and duration in months, or check Therapy Not Medically Necessary.
  • The physician must sign in their original signature, or by electronic signature meeting Arkansas Code 25-31-103. If the EHR cannot meet those criteria, print, sign and date the form.
  • Renewal every six months follows Section I 171.400 and Section II 214.00 of the Arkansas Medicaid therapy provider manual.

Get the official form

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

Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 Prescription/Referral

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How this list is checked

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.

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Frequently asked questions

How often must the Arkansas DMS-640 be renewed?

Therapy providers are responsible for obtaining a renewed PCP referral every 6 months, under Section I 171.400 and Section II 214.00 of the Arkansas Medicaid therapy services provider manual. The physician also certifies that, for a continuing plan, they reviewed the child's progress and adjusted the plan.

Can the DMS-640 be signed electronically?

Yes, if the electronic signature meets Arkansas Medicaid's criteria in Arkansas Code 25-31-103. When an EHR cannot be configured to meet them, the provider prints, signs and dates the form. A scanned copy of the original kept in a retrievable format satisfies the record requirement.

Who signs the DMS-640 if the child has no PCP?

When the Medicaid-eligible child is exempt from PCP requirements, the prescribing attending physician prints their name and provider ID number or taxonomy code in the attending physician line and signs. Otherwise the child's primary care physician signs as PCP.