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Arkansas DMS-693: EPSDT Prescription/Referral

Arkansas Medicaid requires the DMS-693 when an EPSDT screen shows a child under 21 needs a medically necessary service or item that the Arkansas Medicaid State Plan does not specifically include. The primary care physician prescribes or refers for the service and certifies that the goals are reasonable. Under EPSDT, services needed to treat or ameliorate a condition found by a screen must be considered even when the State Plan does not otherwise cover them.

Who completes it

The primary care physician completes and signs the whole form: prescription or referral checkbox, date of last physical exam, medical, developmental and other diagnoses, prescribed treatment, and PCP name with provider ID or taxonomy code.

Submitting and payment

How to submit it
The form is mailed to the Arkansas Division of Medical Services Utilization Review unit; a copy of the EPSDT screen results (CMS-1500) may be attached.
Who pays
The form sets no fee for the PCP; it requests Medicaid coverage of the prescribed EPSDT service.

Good to know

  • Check Section I of the Arkansas Medicaid Child Health Services (EPSDT) manual first. Services already listed there as covered do not need this form.
  • By signing, the PCP certifies they reviewed the EPSDT screen result. For a continuing plan, they also certify they reviewed progress and adjusted the plan to the goals met or missed.
  • The form separates the medical diagnosis from the developmental diagnosis, so a child's developmental findings can be recorded on their own line.
  • The current version is printed DMS-693 (12/10) and is distributed as a Word document.

Get the official form

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

EPSDT Prescription/Referral for Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan

Official pageWord file

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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

When is Arkansas DMS-693 used instead of a regular referral?

It is used when a service or item resulting from an EPSDT screen is medically necessary but is not specifically included in the Arkansas Medicaid State Plan. Under EPSDT, services needed to treat or ameliorate a condition found by a screen must be considered for beneficiaries under 21 even if the State Plan does not otherwise cover them.

Who can sign the Arkansas DMS-693?

The child's primary care physician signs and dates it, printing their name and provider identification number or taxonomy code. The signature certifies that the PCP carefully reviewed the EPSDT screen result and that the goals are reasonable and appropriate for the patient.