The Department of Social Services has free forms and publications that can provide you with information and guidance in a number of important areas.

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Abuse and Neglect

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/ASA2	Abuse, Neglect & Exploitation of Elders or Adults with Disabilities	n/a	n/a	n/a
BRO/CPS11	Central Registry of Child Abuse & Neglect	n/a	n/a
BRO/CPS4	Mandatory Reporting of Child Abuse & Neglect Brochure	n/a	n/a
CPS-549	Request for Screening for Substantial Reports of Abuse and Neglect (unregistered family day care providers ONLY)	n/a		n/a
CPS-593	Permission to Screen for Reports of Abuse or Neglect	n/a

Administrative Hearings

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/DSS3	Administrative Hearings Brochure	n/a	n/a	n/a
DSS	Guide to Administrative Hearings Procedure	n/a	n/a	n/a
EA-319	Request for Administrative Hearing	n/a	n/a	n/a

Adoption and Foster Care

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/CPS5	What I Should Know About Foster Care	n/a	n/a
BRO/CPS9	Adoption Subsidy Handbook	n/a	n/a	n/a
CPS	Background Information for Voluntary Termination of Parental Rights	n/a	n/a	n/a
CPS	Foster Parent Handbook	n/a	n/a	n/a
CPS-506	Foster/Adoptive Parent Health Report	n/a	n/a	n/a
CPS-508	Reference Form - Adoption / Foster / Kinship Care	n/a		n/a
CPS-533	Adoption Registry Form			n/a
CPS-565	Foster Parent Training & Self-Instruction	n/a
CPS-566	Foster Parent Evaluation	n/a
CPS-594	Declaration of Prior Criminal Conviction & Military History	n/a		n/a

Assisted Living and Nursing Homes

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/ASA7	Ombudsman Services Brochure	n/a	n/a	n/a
BRO/ASA8	Assisted Living Centers: Residents Bill of Rights Handbook	n/a	n/a	n/a
MISC/ASA6	Assisted Living in SD: A Consumers Guide	n/a	n/a	n/a
MISC/ASA8	Long-Term Care Facilities: Residents Bill of Rights Handbook	n/a	n/a	n/a

Behavioral Health

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BH-01	Federal Poverty Level Guidelines	n/a		n/a
BH-02	Financial Eligibility Form	n/a		n/a
BH-03	102a Hardship Considerations	n/a		n/a
BH-04	102b Hardship Considerations	n/a		n/a
BH-05	Hardship Considerations Refusal	n/a		n/a
BH-06	3rd Party Release of Information (ROI)	n/a		n/a
BH-07	Mental Health - Accreditation Application	n/a		n/a
BH-08	Mental Health - IMPACT Application	n/a		n/a
BH-09	Mental Health - Indigent Medication Application	n/a		n/a
BH-11	Mental Health - Adult Outcome Tool		n/a	n/a
BH-11a	Adult SUD Initial Outcome Tool	n/a	n/a	n/a
BH-11b	Adult SUD Update Outcome Tool	n/a	n/a	n/a
BH-11c	Adult SUD Discharge Outcome Tool	n/a	n/a	n/a
BH-11d	Adult MH Initial Outcome Tool	n/a	n/a	n/a
BH-11e	Adult MH Update Outcome Tool	n/a	n/a	n/a
BH-11f	Adult MH Discharge Outcome Tool	n/a	n/a	n/a
BH-12	Mental Health - Youth Outcome Tool			n/a
BH-13	Mental Health - Family Outcome Tool		n/a	n/a
BH-14	Substance Abuse - Accreditation Application	n/a		n/a
BH-17	Prevention - Accreditation Application	n/a		n/a
BH-18	Mental Health - Indigent Medication Update - Extension Form 1.0	n/a		n/a
BH-19	Substance Use Disorder High Intensity Referral Form	n/a		n/a

Child Care Services

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/CCS14	Choosing Child Care Handbook	n/a	n/a
BRO/CCS3	Registration & Licensure of Child Care Environments	n/a	n/a
BRO/CCS6	Child Care Assistance Program Brochure	n/a	n/a
CCS	Pathways to Professional Development - Career Lattice Application Form	n/a	n/a	n/a
CCS	Pathways to Professional Development	n/a	n/a	n/a
CCS	Orientation Training Verification Form	n/a	n/a	n/a
CCS	South Dakota Child Safety Seat Distribution Program	n/a	n/a	n/a
CCS	Electronic Payment Exemptions	n/a	n/a	n/a
CCS	Payment Authorization Form	n/a	n/a	n/a
CCS	Foster Care Child Care Application	n/a		n/a	n/a	n/a
CCS-950	Child Care Assistance Application	n/a		n/a
CCS-970	Child Care Services Request For Payment	n/a	n/a	n/a
DSS-CCS	Rate Declaration Form	n/a	n/a	n/a
Poster	Recommendations for Exclusion from the Child Care Setting Poster	n/a	n/a	n/a
Poster	Reportable Disease List Poster	n/a	n/a	n/a

Child Protection Services

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/CPS1	Child Protection Services Booklet	n/a	n/a
BRO/CPS15	Family Group Conferencing – My Family Meeting	n/a	n/a	n/a
BRO/CPS16	Family Group Conferencing – Family Group Decision Making	n/a	n/a	n/a
BRO/CPS17	Family Group Conferencing – Parents Guide	n/a	n/a	n/a
BRO/CPS18	Family Group Conferencing – Provider Guide	n/a	n/a	n/a
BRO/CPS3	Safe Havens Brochure	n/a	n/a
BRO/CPS7	Independent Living Program Education and Training Voucher Brochure	n/a	n/a	n/a
CPS	ICPC Financial and Medical Plan	n/a	n/a	n/a
CPS	Potential Placement Statement	n/a	n/a	n/a
CPS	Placement Resource Monthly Reporting Form Ages 0-4	n/a	n/a	n/a
CPS	Placement Resource Monthly Reporting Form Ages 14 and older	n/a	n/a	n/a
CPS	Placement Resource Monthly Reporting Form Ages 5-13	n/a	n/a	n/a
CPS	Designated Tribal Agent Request Form	n/a	n/a	n/a
CPS	Independent Living Program Brochure	n/a	n/a	n/a
CPS	Provider Mileage Request	n/a	n/a	n/a
CPS	Independent Living Program Education and Training Voucher		n/a	n/a
CPS	Background Information for Voluntary Termination of Parental Rights	n/a	n/a	n/a
CPS	Designated Tribal Agent Request for Change of Address	n/a	n/a	n/a
CPS-500	Newborn Medical Report for Voluntary Termination of Parental Rights	n/a		n/a
CPS-522	Request for Payment	n/a		n/a
DSS-CPS	Safe Havens Poster	n/a	n/a	n/a
FACIS	Interstate Compact: Placement Request Form			n/a
FACIS	Interstate Compact: Report on Child Placement			n/a

Child Support

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/DCS1	Child Support Modification Handbook	n/a	n/a
BRO/DCS2	Teenage Parents Guide - How to Establish Paternity and Financial Support for your Child	n/a	n/a	n/a
BRO/DCS3	Income and Wage Withholding Brochure - Information for SD Employers, Financial Institutions, and Other Payors of Income	n/a	n/a	n/a
BRO/DCS4	National Medical Support Notice Brochure - An Employers Guide	n/a	n/a	n/a
BRO/DCS6	Voluntary Paternity Establishment Handbook and Form	n/a	n/a
BRO/DCS8	Child Support Parent Handbook	n/a	n/a
SE-405	Application for Income Withholding Only Service	n/a	n/a	n/a
SE-406	Application for Location Only Services	n/a	n/a	n/a
SE408CP	Application and Agreement for Services - Custodial Parent and/or Caretaker	n/a	n/a	n/a
SE408NCP	Application and Agreement for Services - Non-Custodial Parent	n/a	n/a	n/a
SE-415	Petition for Modification Form	n/a	n/a	n/a
SE-431A	Child Support Payment Authorization Form	n/a	n/a	n/a
SE-492	Notice of Shared Medical Expenses	n/a	n/a	n/a

Domestic Violence

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/ASA4	Sexual Assault Brochure	n/a	n/a	n/a
BRO/ASA9	Domestic Violence Brochure	n/a	n/a	n/a

Elderly Services

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
ASA	Caregiver Self Assessment	n/a	n/a	n/a
ASA	Make a Referral	n/a		n/a	n/a	n/a
ASA	Guide to Medicare, Medicare Supp Insurance and Beneficiary Resources	n/a		n/a	n/a	n/a
ASA	Application for Guardianship or Conservatorship Services	n/a	n/a	n/a
ASA-522	Request for Payment	n/a	n/a	n/a
ASA-634	Provider Forms: Initial and Continuing Need for Care Report	n/a		n/a
ASA-659	Physician Report - Order	n/a	n/a	n/a
ASA-668	Homemaker Services Report	n/a	n/a	n/a
ASA-677	Prescription Assistance	n/a	n/a	n/a
ASA-694	Crime Victims Compensation Application	n/a	n/a	n/a
BRO/ASA	Long-Term Care Partnership Fact Sheet	n/a	n/a	n/a
BRO/ASA	Long-Term Care Partnership Stuffer	n/a	n/a	n/a
BRO/ASA	Long-Term Care Partnership Brochure	n/a	n/a	n/a
BRO/ASA1	Aging & Disability Resource Connections (ADRC)	n/a	n/a	n/a
BRO/ASA10	Planning for Health Care Decisions: Your Right to Choose	n/a	n/a	n/a
BRO/ASA11	Crime Victims Compensation Brochure	n/a	n/a	n/a
BRO/ASA12	Helping You Understand Medicare & Your Benefits	n/a	n/a	n/a
BRO/ASA2	Abuse, Neglect & Exploitation of Elders or Adults with Disabilities	n/a	n/a	n/a
BRO/ASA3	Adult Services and Aging Programs Handbook	n/a	n/a
BRO/ASA5	Legal Services for the Elderly Brochure	n/a	n/a	n/a
EA-240	Application for Long Term Care or Related Medical Assistance	n/a	n/a

General

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/EA11	Weatherization Assistance Brochure	n/a	n/a
BRO/EA12	Energy Assistance Brochure	n/a	n/a
EA	Weatherization Application	n/a	n/a
EA-297	Energy Assistance Application
EA-301MA	Children and Family Medical Assistance Supplemental Application	n/a	n/a
ENERGY	Vendor Information: Direct Deposit			n/a
ENERGY-927	Vendor Information: Vendor Claim Form			n/a	n/a	n/a

General Social Service Documents

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/DSS2	Constituent Liaison Services Brochure	n/a	n/a	n/a
BRO/DSS6	Filing a Discrimination Complaint Brochure and Form	n/a	n/a	n/a
BRO/DSS8	Notice of Privacy Brochure	n/a	n/a
BRO/DSS9	DSS Handbook	n/a	n/a	n/a
BRO/EA	Community Action Agency Handout	n/a	n/a	n/a
BRO/EA1	Energy Saving Tips	n/a	n/a	n/a
DSS-W9	W-9 Form	n/a	n/a	n/a
EA-301	Economic Assistance Application	n/a
EA-310	Form for Reporting Changes	n/a	n/a
Poster	Constituent Liaison Services Poster	n/a	n/a	n/a

Medical Eligibility

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/EA14	Medical Assistance for Children and Families	n/a	n/a	n/a
BRO/EA16	Medical Assistance for Children and Families: IHS Specific	n/a	n/a	n/a
BRO/EA3	CHIP Brochure	n/a	n/a
BRO/EA5	Medicare Savings Program Brochure	n/a	n/a	n/a
BRO/EA8	Medicaid Spousal Care Handbook	n/a	n/a	n/a
BRO/MS1	Medical Assistance Program Recipient Handbook	n/a	n/a
EA-208	Authorization to Furnish / Release Information	n/a	n/a
EA-208	Authorization to Furnish / Release Information	n/a	n/a
EA-240	Application for Long Term Care or Related Medical Assistance	n/a	n/a
EA-265	Request for Long-Term Care or Home Community Based Services Waiver Assistance	n/a	n/a	n/a
EA-269	Child Care Expense Billing Information	n/a	n/a	n/a
EA-270	Medical Savings Program Application	n/a	n/a
EA-320	Self-Employment Ledger	n/a	n/a
FSSA	Children and Family Medical Assistance Application	n/a	n/a	n/a
Poster	CHIP Poster	n/a	n/a	n/a
Poster	CHIP Poster	n/a	n/a	n/a

Medical Services

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
	Recipient Forms: HIPAA Privacy Consent Form	n/a		n/a
	Primary Care Provider Program Reminders - Emergency Room	n/a		n/a	n/a	n/a
BRO/MS1	Medical Assistance Program Recipient Handbook	n/a	n/a
BRO/MS3	Well-Child Care Brochure	n/a	n/a
BRO/MS4	Title XIX Medical Transportation Brochure	n/a	n/a	n/a
DSS	Recipient Forms: Psychiatric Residential Treatment Facility Referral Form	n/a	n/a	n/a
EA-231	Recipient Forms: Child Support Enforcement Referral	n/a
EA-249	Disabled Children Application / Eligibility Review		n/a	n/a
EA-269	Recipient Forms: Child Care Expense Billing Information	n/a	n/a	n/a
EA-270	Medical Savings Program Application	n/a	n/a
MS	Prior Authorization Forms: Durable Medical Equipment and Nutrition			n/a
MS	Prior Authorization Forms: General Prior Authorization Request			n/a
MS	Hysterectomy Acknowledgement of Information	n/a	n/a	n/a
MS	Prior Authorization Forms: BRCA Prior Authorization	n/a	n/a	n/a
MS	Title XIX Non-Emergency Transportation Payment Authorization Form	n/a	n/a	n/a
MS	Providers: Adult Services & Aging Provider Agreement		n/a	n/a
MS	Prior Authorization Forms: Synagis Prior Authorization	n/a		n/a
MS	Providers: NEMT Provider Agreement			n/a
MS	Self-Audit Worksheet	n/a		n/a	n/a	n/a
MS	Institutional Billing Manual	n/a	n/a	n/a
MS	Pharmacy Billing Manual	n/a	n/a	n/a
MS	Prior Authorization Manual	n/a	n/a	n/a
MS	Professional Services Billing Manual	n/a	n/a	n/a
MS-102	Provider Selection Form	n/a		n/a
MS-103	Provider Change Form	n/a		n/a
MS-146	Sterilization Consent Form	n/a	n/a	n/a
OS-950	Recipient Forms: Title XIX Medical Transportation Reimbursement	n/a	n/a	n/a
PA	Prior Authorization Forms: Private Duty Nursing & Extended Home Health Services	n/a	n/a	n/a
PA	Prior Authorization Forms: Out-of State Services	n/a	n/a	n/a
PA	Prior Authorization Forms: Applied Behavior Analysis Therapy	n/a	n/a	n/a

Nutrition

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/ASA	Senior Meals Brochure	n/a	n/a	n/a
Poster	Senior Meals Poster	n/a	n/a	n/a

Parent Education

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/CPS2	Common Sense Parenting Brochure	n/a	n/a
CPS	Common Sense Parenting Annual Report Form	n/a		n/a	n/a	n/a
CPS	Common Sense Parenting Program Voucher	n/a		n/a	n/a	n/a

Psychiatric Residential Treatment

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
DSS	Psychiatric Residential Treatment Facility Referral Form	n/a	n/a	n/a

Recoveries and Fraud

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/RE1	Stop Benefit Fraud Brochure	n/a	n/a
BRO/RE3	Estate Recovery Program Brochure	n/a	n/a	n/a
BRO/RE4	Medicaid Liens Brochure	n/a	n/a	n/a
DSS-ORFI-831	Estate Recovery Notification of Death Form	n/a	n/a	n/a
Rec and Fraud	Estate Recovery Program Petition for Limitation	n/a		n/a
Rec and Fraud	Report Benefit Fraud	n/a		n/a
Rec and Fraud	Casualty Settlement Report Form	n/a		n/a
Rec and Fraud	Stop Benefit Fraud Insert	n/a	n/a	n/a

SNAP (Food Stamps)

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/EA10	SNAP for Students	n/a	n/a	n/a
BRO/EA2	SNAP Brochure	n/a	n/a
BRO/EA9	SNAP Shoppers Guide	n/a	n/a	n/a
EA-208	Authorization to Furnish / Release Information	n/a	n/a
EA-214	SNAP 6 Month Report Form	n/a	n/a
EA-269	Child Care Expense Billing Information	n/a	n/a	n/a
EA-301	SNAP Application	n/a
EA-305	Boarding School-Institution Documentation	n/a	n/a	n/a
EA-307	SNAP Exit Form	n/a	n/a	n/a
EA-307G	SNAP Group Home Exit Form	n/a	n/a	n/a
EA-320	Self-Employment Ledger	n/a	n/a
EA-324	Wage Verification	n/a	n/a	n/a
EA-345	Affidavit for SNAP Work Registrants	n/a	n/a	n/a
EA-345A	Affidavit for SNAP Work Registrants (Employment & Training)	n/a	n/a	n/a
EA-347	Application for Social Security Number	n/a		n/a
OS-954	Client Authorized Debit for Repayment of Overissuance	n/a	n/a	n/a

South Dakota EBT

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/DSS4	Direct Deposit Brochure	n/a	n/a	n/a
BRO/EBT1	EBT Client Handbook	n/a	n/a

Temporary Assistance for Needy Families

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRO/EA4	TANF Work Program Brochure	n/a	n/a
EA-208	Authorization to Furnish / Release Information	n/a	n/a
EA-214	TANF 6 Month Report Form	n/a	n/a
EA-231	Child Support Enforcement Referral	n/a
EA-260	Statement of Earnings	n/a		n/a
EA-320	Self-Employment Ledger	n/a