Forms & Publications :: SD Dept. of Social Services

Amy Iversen-Pollreisz
Interim Secretary

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Below you will find the selected forms and/or publications for this order. You will need to indicate the quantity you want to receive in the box next to the document number. After you have entered the quantity, click "Update" in the previous box. If you wish to remove a form or publication, simply click on the link that states "Delete." Once you have entered the quantity for each form or publication, click the "Proceed" button at the bottom.

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Copies	Edit the Number of Copies	Document Number	Document Name	Delete
1	Edit	BH-07	Mental Health - Accreditation Application	Delete
1	Edit	BRO/RE1	Stop Benefit Fraud Brochure	Delete
1	Edit	BRO/BH4	Substance Use Disorder Involuntary Commitment Process	Delete
1	Edit	BH-11a	Adult SUD Initial Outcome Tool	Delete
1	Edit	OS-950	Recipient Forms: Title XIX Medical Transportation Reimbursement	Delete
1	Edit	EA-324	Wage Verification	Delete
1	Edit	CCS	Pathways to Professional Development - Career Lattice Application Form	Delete
1	Edit	CPS-508	Reference Form - Adoption / Foster / Kinship Care	Delete
1	Edit	SE408CP	Application and Agreement for Services - Custodial Parent and/or Caretaker	Delete
1	Edit	BRO/CPS17	Family Group Conferencing – Parents Guide	Delete
1	Edit	FACIS	Interstate Compact: Report on Child Placement	Delete
1	Edit	BRO/CPS4	Mandatory Reporting of Child Abuse & Neglect Brochure	Delete
1	Edit	EA-214	TANF 6 Month Report Form	Delete
1	Edit	Poster	Constituent Liaison Services Poster	Delete
1	Edit	BRO/EA16	Medical Assistance for Children and Families: IHS Specific	Delete
1	Edit	BH-11c	Adult SUD Discharge Outcome Tool	Delete
1	Edit	BRO/CPS1	Child Protection Services Booklet	Delete
1	Edit	Poster	CHIP Poster	Delete
1	Edit	BRO/EA2	SNAP Brochure	Delete
1	Edit	CCS	Orientation Training Verification Form	Delete
1	Edit	SE-492	Notice of Shared Medical Expenses	Delete
1	Edit	BRO/CPS7	Independent Living Program Education and Training Voucher Brochure	Delete
1	Edit	BRO/EA8	Medicaid Spousal Care Handbook	Delete
1	Edit	BRO/DCS8	Child Support Parent Handbook	Delete
1	Edit	CCS	Electronic Payment Exemptions	Delete
1	Edit	BRO/DSS8	Notice of Privacy Brochure	Delete
1	Edit	EA-320	Self-Employment Ledger	Delete
1	Edit	BH-11e	Adult MH Update Outcome Tool	Delete
1	Edit	BRO/DSS2	Constituent Liaison Services Brochure	Delete
1	Edit	DSS-CPS	Safe Havens Poster	Delete
1	Edit	BRO/EA12	Energy Assistance Brochure	Delete
1	Edit	BRO/RE3	Estate Recovery Program Brochure	Delete
1	Edit	BRO/CPS2	Common Sense Parenting Brochure	Delete
1	Edit	BRO/EA4	TANF Work Program Brochure	Delete
1	Edit	BRO/RE4	Medicaid Liens Brochure	Delete
1	Edit	BH-13e	Family MH Update Outcome Tool	Delete
1	Edit	Poster	CHIP Poster	Delete
1	Edit	OS-954	Client Authorized Debit for Repayment of Overissuance	Delete
1	Edit	BH-04	102b Hardship Considerations	Delete
1	Edit	BRO/DCS4	National Medical Support Notice Brochure - An Employers Guide	Delete
1	Edit	CPS	Provider Mileage Request	Delete
1	Edit	CPS-533	Adoption Registry Form	Delete
1	Edit	Poster	Reportable Disease List Poster	Delete
1	Edit	DSS	Psychiatric Residential Treatment Facility Referral Form	Delete
1	Edit	BRO/DSS3	Administrative Hearings Brochure	Delete
1	Edit	MS	Medicaid Non-Emergency Travel (NEMT) Payment Authorization Form	Delete
1	Edit	EA-347	Application for Social Security Number	Delete
1	Edit	SE-415	Petition for Modification Form	Delete
1	Edit	BRO/EA	Community Action Agency Handout	Delete
1	Edit	DSS-CCS	Rate Declaration Form	Delete
1	Edit	SE-406	Application for Location Only Services	Delete
1	Edit	BRO/EA11	Weatherization Assistance Brochure	Delete
1	Edit	BH-18	Substance Use Disorder High Intensity Referral Form	Delete
1	Edit	PA	Prior Authorization Forms: Durable Medical Equipment and Nutrition	Delete
1	Edit	EA-307	SNAP Exit Form	Delete
1	Edit	CPS	ICPC Financial and Medical Plan	Delete
1	Edit	PA	Prior Authorization Forms: Private Duty Nursing & Extended Home Health Services	Delete
1	Edit	DSS-W9	W-9 Form	Delete
1	Edit	BH-06	3rd Party Release of Information (ROI)	Delete
1	Edit	BRO/DCS6	Voluntary Paternity Establishment Handbook and Form	Delete
1	Edit	BRO/CCS3	Registration & Licensure of Child Care Environments	Delete
1	Edit	BRO/EA14	Medical Assistance for Children and Families	Delete
1	Edit	CPS-549	Request for Screening for Substantial Reports of Abuse and Neglect (unregistered family day care providers ONLY)	Delete
1	Edit	CPS	Background Information for Voluntary Termination of Parental Rights	Delete
1	Edit	MS	Hysterectomy Acknowledgement of Information	Delete
1	Edit	EA-297	Energy Assistance Application	Delete
1	Edit	CPS	Placement Resource Monthly Reporting Form Ages 0-4	Delete
1	Edit	EA-269	Child Care Expense Billing Information	Delete
1	Edit	SE-405	Application for Income Withholding Only Service	Delete
1	Edit	EA-298	Weatherization Application	Delete
1	Edit	BRO/EA18	Long-Term Care Partnership Brochure	Delete
1	Edit	BH-11b	Adult SUD Update Outcome Tool	Delete
1	Edit	DSS-ORFI-831	Estate Recovery Notification of Death Form	Delete
1	Edit	BRO/EA9	SNAP Shoppers Guide	Delete
1	Edit	EA-301	SNAP Application	Delete
1	Edit		Recipient Forms: HIPAA Privacy Consent Form	Delete
1	Edit	BRO/MS1	Medical Assistance Program Recipient Handbook	Delete
1	Edit	BRO/MS3	Well-Child Care Brochure	Delete
1	Edit	BRO/CPS18	Family Group Conferencing – Provider Guide	Delete
1	Edit	EA-301	Economic Assistance Application	Delete
1	Edit	BRO/CPS3	Safe Havens Brochure	Delete
1	Edit	BRO/EBT1	EBT Client Handbook	Delete
1	Edit	ENERGY	Vendor Information: Direct Deposit	Delete
1	Edit	BRO/DSS9	DSS Handbook	Delete
1	Edit	CPS	Independent Living Program Education and Training Voucher	Delete
1	Edit	EA-305	Boarding School-Institution Documentation	Delete
1	Edit	BRO/EA10	SNAP for Students	Delete
1	Edit	BRO/DSS6	Filing a Discrimination Complaint Brochure and Form	Delete
1	Edit	BRO/EA5	Medicare Savings Program Brochure	Delete
1	Edit	BH-09a	Indigent Medication Update-Extension Application	Delete
1	Edit	BRO/DCS1	Child Support Modification Handbook	Delete
1	Edit	Rec and Fraud	Casualty Settlement Report Form	Delete
1	Edit	BRO/CPS11	Central Registry of Child Abuse & Neglect	Delete
1	Edit	MS-102	Provider Selection Form	Delete
1	Edit	EA-208	Authorization to Furnish / Release Information	Delete
1	Edit	EA-260	Statement of Earnings	Delete
1	Edit	BH-09	Indigent Medication Application	Delete
1	Edit	Rec and Fraud	Stop Benefit Fraud Insert	Delete
1	Edit	EA-310	Form for Reporting Changes	Delete
1	Edit	EA-269	Child Care Expense Billing Information	Delete
1	Edit	SE-431A	Child Support Payment Authorization Form	Delete
1	Edit	BRO/DCS3	Income and Wage Withholding Brochure - Information for SD Employers, Financial Institutions, and Other Payors of Income	Delete
1	Edit	EA-240D	Application for Medical Assistance for Workers with Disabilities	Delete
1	Edit	CCS-950	Child Care Assistance Application	Delete
1	Edit	BRO/CCS6	Child Care Assistance Program Brochure	Delete
1	Edit	BRO/DSS4	Direct Deposit Brochure	Delete
1	Edit	EA-320	Self-Employment Ledger	Delete
1	Edit	MS-146	Sterilization Consent Form	Delete
1	Edit	BRO/EA1	Energy Saving Tips	Delete
1	Edit	EA-345	Affidavit for SNAP Work Registrants	Delete
1	Edit	BH-11	Behavioral Health Treatment Outcomes Program Manual	Delete
1	Edit	POS/EA02	Long-Term Care Partnership Fact Sheet	Delete
1	Edit	BRO/MS1	Medical Assistance Program Recipient Handbook	Delete
1	Edit	MS	Providers: Adult Services & Aging Provider Agreement	Delete
1	Edit	PA	Prior Authorization Forms: BRCA	Delete
1	Edit	BRO/MS4	Title XIX Medical Transportation Brochure	Delete
1	Edit	CCS	Pathways to Professional Development - Renewal Application	Delete
1	Edit	FSSA	Children and Family Medical Assistance Application	Delete
1	Edit	CCS	South Dakota Child Safety Seat Distribution Program	Delete
1	Edit	BH-05	Hardship Considerations Refusal	Delete
1	Edit	BRO/DCS2	Teenage Parents Guide - How to Establish Paternity and Financial Support for your Child	Delete
1	Edit	CPS	Independent Living Program Brochure	Delete
1	Edit	PA	Prior Authorization Forms: Applied Behavior Analysis Therapy	Delete
1	Edit	CPS-594	Declaration of Prior Criminal Conviction & Military History	Delete
1	Edit	BRO/CCS14	Choosing Child Care Handbook	Delete
1	Edit	CPS	Designated Tribal Agent Request for Change of Address	Delete
1	Edit	BRO/CPS15	Family Group Conferencing – My Family Meeting	Delete
1	Edit	DSS	Guide to Administrative Hearings Procedure	Delete
1	Edit	EA-307G	SNAP Group Home Exit Form	Delete
1	Edit	CPS	Potential Placement Statement	Delete
1	Edit	PA	Prior Authorization Forms: Out-of State Services	Delete