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The General Prior Authorization Request Form is to be completed by the prescribing physician for all covered services requiring prior authorization for Medical Assistance Program eligible recipients.
This form is to be used by providers as written documentation to support medical necessity and must be completed and maintained in the patient’s medical record prior to submitting a claim to the South Dakota Medical Assistance Program.
Mail your completed form to:
Division of Medical Services
700 Governors Drive
Pierre, SD 57501
Phone: (605) 773-3495
Fax: (605) 773-5246