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Arkansas DMS-679: Medical Equipment Rx & PA Request

Arkansas Medicaid uses the DMS-679 as both the prescription and the prior authorization request for durable medical equipment other than wheelchairs. The DME provider lists the items and codes, and the prescribing physician or APRN certifies medical necessity with diagnoses, length of need and measurements. The provider submits it to the Arkansas Medicaid prior authorization contractor for review.

Who completes it

The DME provider completes Section A (request type, beneficiary, provider, prescriber and procedure codes) and signs its attestation. The prescribing physician or APRN completes Section B: estimated length of need, EPSDT referral, height and weight, up to four diagnoses with ICD codes, home use, and signature.

Submitting and payment

How to submit it
The DME provider submits the completed form, with documentation supporting medical necessity, to the Arkansas Medicaid prior authorization contractor.
Who pays
The form sets no fee for the prescriber; it supports the DME provider's prior authorization for the equipment.

Good to know

  • Signature and date stamps are not acceptable in Section B. The prescribing physician or APRN must sign and date it personally, within their scope of practice.
  • List the diagnosis that is the primary reason for the item first, then up to three more ICD codes that further describe the medical need.
  • If the PCP is not the prescriber, Section B asks for the PCP's name and Medicaid ID number as well.
  • Wheelchairs and wheelchair seating are excluded and use DMS-0843 instead. Request types are initial, recertification, modification and extension of benefits; the version is dated 9/1/18.

Get the official form

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

Prescription & Prior Authorization Request for Medical Equipment

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Frequently asked questions

What does the prescriber complete on Arkansas DMS-679?

Section B: the estimated length of need in weeks, months or lifetime, whether the request results from an EPSDT referral, the beneficiary's current height and weight, up to four diagnoses with ICD codes, and whether the equipment is for use in the home. The physician or APRN then prints their name and Medicaid ID, signs without a stamp and dates.

Does DMS-679 need supporting documentation?

Yes. The instructions state that documentation supporting medical necessity of the requested items must be submitted with the request. The signed Section B statement that the equipment is medically necessary does not replace the clinical records behind it.