Form DMS-846 "Practice Withdrawal Form - Arkansas Patient-Centered Medical Home Program" - Arkansas

This version of the form is not currently in use and is provided for reference only.
Download this version of Form DMS-846 for the current year.

What Is Form DMS-846?

This is a legal form that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Arkansas Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DMS-846 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form DMS-846 "Practice Withdrawal Form - Arkansas Patient-Centered Medical Home Program" - Arkansas

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Division of Medical Services
Arkansas Patient-Centered Medical Home
Enrollment Unit
1-866-322-4696 (in-state) or 1-501-301-8311 (local and out-of state)
Fax: 501-374-0549 TDD/TTY: 501-682-6789
Email:
ARKPCMH@dxc.com
Arkansas Patient-Centered Medical Home Program
Practice Withdrawal Form
PRACTICE IDENTIFICATION:
1. Practice Name:
2. Practice Address:
3. Medicaid Billing ID#:
4. National Provider ID#:
5. Name(s) of pooling partner(s):
(if applicable)
WITHDRAWAL STATEMENT:
By signing this withdrawal form, ___________________________________________, hereafter known
as “the Practice,” is requesting to withdraw from the ____________ configuration of the Arkansas Patient-
Centered Medical Home (PCMH) Program, effective ______________, understanding that this withdrawal
form serves to terminate the PCMH Program contract that exists between Arkansas Medicaid and the
Practice. The Practice acknowledges that all potential payments for practice support and Shared Savings
incentives under the PCMH Program will cease immediately and that any outstanding overpayment may
be reconciled by Arkansas Medicaid through reduction of future Medicaid fee-for-service reimbursement.
PRACTICE AUTHORIZATION:
Representative’s Name and Title (please print)
Representative’s Signature
Signature Date
Representative’s Phone#:
Representative’s Email address:
DMS AUTHORIZATION:
DMS Representative’s Name and Title (please print)
DMS Representative’s Signature
Signature Date
DMS-846 (02/18)
NOTICE: Information included in this form is protected under HIPAA rules. The information is disclosed to the healthcare provider
(covered entity) only for carrying out healthcare operations. The information must be safeguarded, used, transmitted, and disclosed
only in accordance with the HIPAA rules. The information contained in this form is intended solely for use in the administration of the
Medicaid program, and is neither intended nor suitable for other uses, including the selection of a health care provider. For more
information, please visit www.paymentinitiative.org.
humanservices.arkansas.gov
Protecting the vulnerable, fostering independence and promoting better health
Division of Medical Services
Arkansas Patient-Centered Medical Home
Enrollment Unit
1-866-322-4696 (in-state) or 1-501-301-8311 (local and out-of state)
Fax: 501-374-0549 TDD/TTY: 501-682-6789
Email:
ARKPCMH@dxc.com
Arkansas Patient-Centered Medical Home Program
Practice Withdrawal Form
PRACTICE IDENTIFICATION:
1. Practice Name:
2. Practice Address:
3. Medicaid Billing ID#:
4. National Provider ID#:
5. Name(s) of pooling partner(s):
(if applicable)
WITHDRAWAL STATEMENT:
By signing this withdrawal form, ___________________________________________, hereafter known
as “the Practice,” is requesting to withdraw from the ____________ configuration of the Arkansas Patient-
Centered Medical Home (PCMH) Program, effective ______________, understanding that this withdrawal
form serves to terminate the PCMH Program contract that exists between Arkansas Medicaid and the
Practice. The Practice acknowledges that all potential payments for practice support and Shared Savings
incentives under the PCMH Program will cease immediately and that any outstanding overpayment may
be reconciled by Arkansas Medicaid through reduction of future Medicaid fee-for-service reimbursement.
PRACTICE AUTHORIZATION:
Representative’s Name and Title (please print)
Representative’s Signature
Signature Date
Representative’s Phone#:
Representative’s Email address:
DMS AUTHORIZATION:
DMS Representative’s Name and Title (please print)
DMS Representative’s Signature
Signature Date
DMS-846 (02/18)
NOTICE: Information included in this form is protected under HIPAA rules. The information is disclosed to the healthcare provider
(covered entity) only for carrying out healthcare operations. The information must be safeguarded, used, transmitted, and disclosed
only in accordance with the HIPAA rules. The information contained in this form is intended solely for use in the administration of the
Medicaid program, and is neither intended nor suitable for other uses, including the selection of a health care provider. For more
information, please visit www.paymentinitiative.org.
humanservices.arkansas.gov
Protecting the vulnerable, fostering independence and promoting better health