The hospital/physician should inform needy individuals of possible medical assistance available under the Medicaid Program. The hospital/physician should refer all interested individuals to Arkansas Department of Human Services by means of Form DMS-630, Referral for Medical Assistance. View or print form DMS-630.

The hospital/physician should be prepared to provide itemized statements on all individuals referred to Arkansas Department of Human Services for potential use in the eligibility determination. The hospital's/physician's representative is responsible for the accurate completion of the Referral Form (DMS-630). After the required information has been entered on the form, the hospital/physician representative will read and explain the authorization section to the client before securing the client's signature. Once the signature is obtained, the hospital/physician representative will sign and date the form and forward it to the local county Human Services office in the client's county of residence.

The County Human Services Office addresses are available from the Arkansas Division of Medical Services.