Medicaid, ARHOME, and ARKids Beneficiaries

Watch for your renewal form, fill it out, and return it to Arkansas Medicaid right away to avoid losing Medicaid coverage if you are eligible.

Search
Close this search box.

Forms & Documents

Forms & Documents

General Forms and Documents

DMS-7734 – Nursing Homes | Incident and Accident Next Day Reporting FormDOC07/30/2012
ARChoices Provider Assurance Statement FormPDF11/09/2023
Counties Served ListPDF11/09/2023
DMS-762 Completion Guidance ToolPDF04/13/2015
DMS-742 – Assisted Living | Incident Investigation FormDOC04/03/2019
Continuing Education (CEU) Workshop Approval | CEU Review ChecklistDOC04/03/2019
DHS-9571 – Options Counseling FormDOC04/03/2019
DHS-9571 – Options Counseling FormDOC04/03/2019
Continuing Education (CEU) Workshop Approval | Biographical InformationDOC04/03/2019
Continuing Education (CEU) Workshop Approval | Attendance CertificateDOC04/03/2019
DMS-787 – Mental Illness/Mental Retardation/Developmental Disability – Level I Identification ScreenDOC11/02/2023
DMS-731 – Assisted Living | Incident Reporting FormDOC04/03/2019
Beneficiary Designation FormDOC04/03/2019
DMS-780 – Dementia Diagnosis Substantiation Form 04/03/2019
DMS-762 – Nursing Homes | Investigation Report for Resident Abuse, Neglect, Misappropriation of PropDOC04/03/2019
DCO-702 – Notice of Admission, Transfer or Discharge from Facility FormDOC04/03/2019
Continuing Education (CEU) Workshop Approval | Evaluation FormDOC04/03/2019
Continuing Education (CEU) Workshop Approval | OLTC Approval RequestDOC04/03/2019
DMS-2602 – TEFRA Waiver | Physician Assessment of EligibilityDOC04/03/2019
Continuing Education (CEU) Workshop Approval | Educational DesignDOC04/03/2019
Suspected Crime Reporting Form under the Elder Justice ActDOC01/06/2012
DMS-726 – Nursing Homes | Licensure/Renewal/Change of Ownership FormDOC01/04/2017
DCO-0004 Application for Healthcare (Long Term Care Application)PDF04/05/2023
OLTC Emergency Preparedness Checklist (Revised March 2014)PDF03/25/2014
DMS-803 – Assisted Living Application for LicensureDOC03/13/2013
DMS-744 – Adult Day Care, Adult Day Health Care, RCF & PAHI | Application for LicensureDOC03/13/2013
DHS-703 – Medical Need Determination Form via Quickbase
DHS-703 – Medical Need Determination Form
PDF03/08/2016

CNA Training

DMS-724 – Certified Nursing Assistant (CNA) | Nursing Assistant Training Program ApplicationDOC10/22/2020
DMS-755 – Nursing Assistant Training Cost Reimbursement Claim Form  
DMS-741 – Certified Nursing Assistant (CNA) | Nursing Assistant Trainee Task Performance Record FormDOC04/03/2019
Out of State Reciprocity FormWEBSITE05/10/2023

Background Check Forms

DMS-7799 – Criminal Record Check | LTC Administrator Criminal Record Check and Information SheetDOC10/22/2020
APS-0001 – Authorization for Adult Maltreatment Central RegistryDOC09/12/2011
State and Federal Criminal Background Check FormPDF09/23/2022
Combined Background Check Form (LTC)PDF01/19/2023
Combined Background Check Form (DDS)PDF01/19/2023
ASP-122 – Criminal Record Check | Generic ASP CRC Form for Non-Mandated (RN, LPN, ETC.) EmployeesPDF10/23/2020
APS-0001 – Authorization for Adult Maltreatment Central RegistryDOC 
ASP-122 – Criminal Record Check | Generic ASP CRC Form for Non-Mandated (RN, LPN, etc) EmployeesPDFR. 02/2012

Nursing Home Administrator

DMS-7790 – Nursing Home Administrators | Application for Nursing Home AdministratorsDOC04/20/2022
DMS-7790-Instruct – Nursing Home Administrator Licensure Application Instructions  
Nursing Home Administrators | Reciprocity Licensing QuestionnaireDOC04/14/2015
DMS-746 – Nursing Home Administrators | Administrator License Renewal FormDOC06/22/2022