Forms and Publications

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

This page can help you find the information you need in the following ways:

		Some forms are available to fill out and submit online. The remaining online forms can be filled out on your computer, printed and mailed.
		You can download any form or publication on this page by clicking on the download button.
		There’s a simple “Shopping Cart” that allows you to place an order for free forms and publications. These documents will then be mailed to you at no cost.
		Instructions are available (Click on icon to view)

If you would like to order any form or publication in English, please click on Forms Only, Publications Only or All. The shopping cart will automatically default to the English version of the form or publication.

If you would like to order any form or publication in Spanish, please click on Documentos en Español. You will find both forms and publication in Spanish in this section. The shopping cart will automatically default to the Spanish version of the form or publication.

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Abuse and Neglect

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BROCPS04	Mandatory Reporting of Child Abuse & Neglect Brochure	n/a	n/a
BROCPS11	Central Registry of Child Abuse & Neglect	n/a	n/a
CPS-504	Present Danger Plan	n/a	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
BRODSS03	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
BROCPS09	Adoption Subsidy Handbook	n/a	n/a	n/a	n/a	n/a
BROCPS19	FosterOne Brochure	n/a	n/a	n/a
BROCPS20	FosterOne – Realities	n/a	n/a	n/a
BROCPS21	FosterOne Myth & Fact	n/a	n/a	n/a
CPS	Foster Parent Handbook	n/a		n/a	n/a	n/a
CPS	Background Information for Voluntary Termination of Parental Rights	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

Behavioral Health

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BROBH01	Substance Use Disorder Services Brochure	n/a	n/a	n/a
BROBH02	Mental Health Services Brochure	n/a	n/a	n/a
BROBH03	Quick Reference Guide	n/a	n/a	n/a
BROBH04	Substance Use Disorder Involuntary Commitment Process	n/a	n/a	n/a
BROBH05	Intensive Methamphetamine Treatment Services	n/a	n/a	n/a
BROHSC01	Mental Health Wellness and Recovery Phone Apps Brochure	n/a	n/a	n/a
FLYRBH01	South Dakota Community Mental Health Center Flyer	n/a	n/a	n/a
FLYRBH02	Suicide Prevention Flyer	n/a	n/a	n/a
FLYRBH03	Substance Use Disorder Services Flyer	n/a	n/a	n/a
FLYRBH04	Juvenile Justice Reinvestment Initiative Flyer	n/a	n/a	n/a
FLYRBH05	Substance Use Prevention Services Flyer	n/a	n/a	n/a
FLYRBH06	Criminal Justice Initiative Flyer	n/a	n/a	n/a

Child Care Services

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BROCCS03	Registration & Licensure of Child Care Environments	n/a	n/a
BROCCS06	Child Care Assistance Program Brochure	n/a	n/a
BROCCS09	South Dakota Child Safety Seat Distribution Program	n/a	n/a	n/a
CC-975	TANF Child Care Benefits Application	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	Orientation Training Verification Form	n/a	n/a	n/a
CCS	Foster Care Child Care Application	n/a		n/a	n/a	n/a
CCS	Pathways to Professional Development - Career Lattice Application Form	n/a	n/a	n/a
CCS	Pathways to Professional Development - Renewal Application	n/a	n/a	n/a
CCS-950	Child Care Assistance Application	n/a		n/a
CCS-964	Child Care Declaration of Prior Criminal Conviction and Military History	n/a	n/a	n/a
CCS-970	Child Care Services Request For Payment	n/a		n/a
DSS-CCS	Rate Declaration Form	n/a	n/a	n/a
EA-269	Child Care Expense Billing Information	n/a	n/a	n/a
HDBKCCS14	Choosing Child Care Handbook	n/a	n/a
Poster	Recommendations for Exclusion from the Child Care Setting Poster	n/a		n/a	n/a	n/a
Poster	Reportable Disease List Poster	n/a		n/a	n/a	n/a

Child Protection Services

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BROCPS03	Safe Havens Brochure	n/a	n/a	n/a
BROCPS07	Independent Living Program Education and Training Voucher Brochure	n/a	n/a
BROCPS10	Independent Living Program Brochure	n/a	n/a
BROCPS13	Young Voices 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	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	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
FACIS	Interstate Compact: Placement Request Form			n/a
FACIS	Interstate Compact: Report on Child Placement			n/a
HDBKCPS01	Child Protection Services Booklet	n/a	n/a
HDBKCPS14	Young Voices Handbook	n/a	n/a	n/a
POSCPS03	Safe Havens Poster	n/a	n/a	n/a

Child Support

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRODCS03	Income and Wage Withholding Brochure - Information for SD Employers, Financial Institutions, and Other Payors of Income	n/a	n/a	n/a
BRODCS04	National Medical Support Notice Brochure - An Employers Guide	n/a	n/a	n/a
BRODCS08	Child Support Parent Handbook	n/a	n/a
HDBKDCS01	Child Support Modification Handbook	n/a	n/a	n/a
HDBKDCS06	Voluntary Paternity Establishment Handbook and Form	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

General

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BROEA11	Weatherization Assistance Brochure	n/a	n/a
BROEA12	Energy Assistance Brochure	n/a	n/a
EA-297	Energy Assistance Application		n/a
EA-298	Weatherization Application	n/a	n/a
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
BRODSS06	Filing a Discrimination Complaint Brochure and Form	n/a	n/a	n/a
BRODSS08	Notice of Privacy Brochure	n/a	n/a
BROEA01	Energy Saving Tips	n/a	n/a	n/a
BROEA18	Long-Term Care Partnership Brochure	n/a	n/a	n/a
BROEA19	Guide to Assistance Handbook	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
FLYREA02	Long-Term Care Partnership Fact Sheet	n/a	n/a	n/a
HDBKDSS09	DSS Handbook	n/a	n/a	n/a

Medical Eligibility

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BROEA05	Medicare Savings Program Brochure	n/a	n/a	n/a
BROEA08	Medicaid Spousal Care Handbook	n/a	n/a	n/a
BROEA14	CHIP Rack Card	n/a	n/a
BROEA16	Medical Assistance for Children and Families: IHS Specific	n/a	n/a	n/a
EA-208	Authorization to Furnish / Release Information	n/a	n/a
EA-240	Application for Resource Assessment, Long Term Care or Related Medical Assistance	n/a	n/a	n/a
EA-240D	Application for Medical Assistance for Workers with Disabilities	n/a	n/a	n/a
EA-249	Disabled Children's Program Application	n/a	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-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
HDBKMS01	Medical Assistance Program Recipient Handbook	n/a	n/a
POSEA03	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
-	Dental At-Risk Referral Form	n/a	n/a	n/a
-	South Dakota Medicaid Pre-Orthodontic Certification Form	n/a	n/a	n/a
-	South Dakota Medicaid Handicapping Labio-Langual Deviations Form (HLD Index)	n/a	n/a	n/a
BROMS02	Provider Selection Rack Card	n/a	n/a	n/a
BROMS03	Well-Child Care Brochure	n/a	n/a
BROMS04	Medicaid Non-Emergency Medical Travel Brochure	n/a	n/a	n/a
BROMS06	Health Home Brochure	n/a	n/a	n/a
BROMS08	Constituent Liaison Services Brochure	n/a	n/a	n/a
HDBKMS01	Medical Assistance Program Recipient Handbook	n/a	n/a
MS	Hysterectomy Acknowledgement of Information	n/a	n/a	n/a
MS	Medicaid Credit Balance Report Form	n/a		n/a	n/a	n/a
MS	Medicaid Transportation Documentation Form	n/a	n/a	n/a
MS	Certificate of Medical Necessity	n/a	n/a	n/a
MS	Transportation Exceptions Form	n/a	n/a	n/a
MS	Medicaid Non-Emergency Travel (NEMT) Payment Authorization Form	n/a	n/a
MS	Hospice Notification	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
OS-950	Recipient Forms: Medicaid Non-Emergency Medical Travel Form	n/a	n/a	n/a
OS-964	Non-Emergency Medical Travel HIPAA Authorization	n/a	n/a	n/a
PA	Prior Authorization Forms: Durable Medical Equipment and Nutrition		n/a	n/a
PA	Prior Authorization Forms: General		n/a	n/a
PA	Prior Authorization Forms: Applied Behavior Analysis Therapy	n/a	n/a	n/a
PA	Prior Authorization Forms: Synagis	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: Genetic Testing	n/a	n/a	n/a
PA	Prior Authorization Forms: BRCA	n/a	n/a	n/a
PA	Prior Authorization Form: Incontinence Supply Family Support 360 Waiver	n/a	n/a	n/a
PA	Prior Authorization Form: Incontinence Supply Supply HOPE Waiver	n/a	n/a	n/a
PA	Prior Authorization Form: Incontinence Supply ADLS Support 360 Waiver	n/a	n/a	n/a
PA	Prior Authorization Form: Incontinence Supply CHOICES Waiver	n/a	n/a	n/a
POSMS08	Constituent Liaison Services Poster	n/a	n/a	n/a

Parent Education

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BROCPS02	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

Recoveries and Fraud

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BRORE03	Estate Recovery Program Brochure	n/a	n/a	n/a
BRORE04	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
BROEA02	SNAP Brochure	n/a	n/a
BROEA09	SNAP Shoppers Guide	n/a	n/a	n/a
BROEA10	SNAP for Students	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
POSEA02	SNAP Notice of Rights Poster	n/a	n/a	n/a

South Dakota EBT

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
HDBKEBT01	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
BROEA04	TANF Work Program Brochure	n/a	n/a
CC-975	TANF Child Care Benefits Application	n/a	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	n/a	n/a
EA-260	Statement of Earnings	n/a		n/a
EA-320	Self-Employment Ledger	n/a