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Prior Authorization

Prior Authorization Request Services and Forms

EPSDT- Special Nutrition

“All special nutrition for children that is medically necessary but falls outside coverage limits requires prior authorization by the Department of Social Services. Please submit the general prior authorization form, prescription and any other documentation that supports the request. Other documentation may include but is not limited to lab or test results, treatment history, letters from providers, medical evaluations, and other medical records.”

Mail or fax your completed form and documentation to:

EPSDT Coordinator
700 Governors Drive
Pierre, SD 57501
Phone: 605-773-3495
Fax: 605-773-5246