Follow the steps to effectively complete the Dms 640 Form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editing tool.
2. Enter the patient name in the designated field, ensuring it is the full legal name of the child.
3. Input the Medicaid ID number of the patient in the corresponding section.
4. Specify the date the child was last seen in the office. This date should reflect any in-person visit, including routine check-ups or examinations.
5. Provide the primary medical diagnosis description or the relevant ICD-9 code in the primary diagnosis field.
6. Detail the diagnosis as it relates to the prescribed treatment in the designated section to establish medical necessity.
7. If the form is to be used for a therapy prescription, fill in the required number of minutes per week and the duration of therapy in months for occupational, physical, or speech therapy.
8. If therapy is deemed not medically necessary, be sure to check the corresponding box to indicate this.
9. Include any additional relevant information regarding the child's medical condition or treatment plan in the other information section.
10. Print the name of the Primary Care Physician (PCP) and their provider identification number and taxonomy code in the specified fields.
11. If applicable, print the name of the attending physician along with their provider identification number and taxonomy code.
12. The prescribing physician must provide their original signature and the date to validate the prescription for therapy.
13. Once all fields are completed, you may save any changes made, download the form for your records, print it for submission, or share it as required.

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