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									                                                                                                                                                                                                                                                                                                                                                                                                                              MEDICAID FORM REQUEST

                                                                                                                                                                                                                                                                                                                                                                                                                                               Please indicate the quantity of forms below:
                                                           ____________________ _____________ _______-_____
                                                                                                                                                                                                                                                                                         Attn/ Care Of:
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DCO-645 (Hospital/Physician/Certified Nurse Midwife Referral
                                                                                                                                                                                                                                                                                                                                                                                                                                             for Newborn Infant Medicaid Coverage)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DHS-754 (Hospice/INH Claim Form)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-26-V (Visual Care)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-601 (Request for Targeted Case Management Prior
                                                                                                                                                                                                                                                                                                                                                                                                                                             Authorization for Beneficiaries Under Age 21)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-615 (Sterilization Consent Form)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-618 (Personal Care Assessment and Service Plan)

                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-619 (Consent for Release of Information)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-630 (Referral for Medical Assistance)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-632 (DDTCS Transportation Survey)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-633 (Mental Health Services Provider Qualification form for
                                                                                                                                                                                                                                                                                                                                                                                                                                             LCSW, LMFT and LPC)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-640 (Occupational, Physical and Speech Therapy for Medicaid
                                                Zip Code

                                                                                                                                                                                                                                                                                                                                                                                                                                             Eligible Beneficiaries Under Age 21 Prescription/Referral)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-671 (Request for Extension of Benefits for Clinical, Outpatient,
                                                                                                                                                                                                                                                                                                                                                                                                                                             Laboratory and X-Ray Services)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-679 (Medical Equipment Request for Prior Authorization
                                                                                                                                                                                                                                                                                                                                                                                                                                             & Prescription)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-699 (Request for Extension of Benefits)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-2606 (Acknowledgement of Hysterectomy Information)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-2609 (Primary Care Physician Selection and Change Form)
                                                                                                                                                                                                                                                                                      Attn: Please PRINT Clearly: The Address, Provider ID and Phone Number

                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-2615 (Prescription & Prior Authorization Request for Nutrition
                                                                                                                                                                                                                                                                                                                                                                                                                                             Therapy & Supplies)
                                                                                                                                                                                                                                                                                            Mail request to: HP Enterprise Services
                                                                                                                                                                                                                                                                                            Fax request to: Attn: Forms Request at (501)374-0549 or

                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-2692 (Request for Private Duty Nursing Services Prior
                                                                                                                                                                                                                                                                                                                                                                                                                                             Authorization and Prescription Initial Request or Recertification)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-0685-14 (Medicaid Prescription Drug Program Prior
  Phone Number: _____________________________

                                                                                        Taxonomy Code: ___________________________

                                                                                                                                                                      Provider ID #: _______________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                             Authorization (PA) Request for Extension of Benefits)

                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ DMS-2698 (Certification Statement for Abortion)
                                                                                                                                                                                                                                                                                                             Little Rock, AR 72203
                                                                                                                                                                                                                                                                                                             PO Box 8033
                                                                                                                                                                                                                                                                                                             Attn: Forms Request

                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ HP-AR-004 (Adjustment Request Form - Medicaid XIX)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ HP-CI-003 (Medicaid Claim Inquiry Form)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ HP-CR-002 (Explanation of Check Refund)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ HP-MFR-001 (Medicaid Form Request)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ HP-MC-001 (Inpatient Services Medicare-Medicaid
                                                                                                                                                                                                                                                                                                                                                                                                                                             Crossover Invoice)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ HP-MC-002 (Long Term Care Services Medicare-Medicaid
                                                                                                                                                                                                                                                                                                                                                                                                                                             Crossover Invoice)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ HP-MC-003 (Outpatient Services Medicare-Medicaid
                                                                                                                                                                                                                                                                                                                                                                                                                                             Crossover Invoice)
                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ HP-MC-004 (Professional Services Medicare-Medicaid
                                                                                                                                                                                                                                                                                                                                                                                                                                             Crossover Invoice)

                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ PUB-019 (Sterilization Consent Form Information for Women)

                                                                                                                                                                                                                                                                                                                                                                                                                                     ______ PUB-020 (Sterilization Consent Form Information for Men)

                                                                                                                                                                                                                                                                                                                                                                                                                          Received                                                  Mailed
  Date                                                                                                                                                                                                                                                                                                                                                                                                                                                    Date
  By                                                                                                                                                                                                                                                                                                                                                                                                                                                      Qty
HP-MFR-001 (Rev. 12/11)

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