Prior Authorization Request Services and Forms

Neonatal Intensive Care Unit

• General Prior Authorization Request Form
• Neonatal Intensive Care Unit Admission Criteria

All stays must be prior authorized by the Department of Social Services. Please send the admissions H and P (History and Physical) within one business day of completion and weekly progress reports to:

Eastern SD:

Nurse Consultant

811 E. 10th Street, Dept #8

Sioux Falls, SD 57103

Phone: 605-367-7601

Fax: 605-367-5253

Western SD:

Nurse Consultant

510 N. Cambell

PO Box 2440

Rapid City, SD 57709-2440

Phone: 605-394-1740

Fax: 605-394-2699