Cabinet Secretary
Laurie R. Gill

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.

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Service Area:

Abuse and Neglect

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
CPS 04	Mandatory Reporting Brochure	n/a	n/a
CPS 11	Central Registry Brochure	n/a	n/a
CPS-501	Individual: Request for Screening	n/a		n/a	n/a	n/a
CPS-502	Agency: Request for Screening	n/a		n/a	n/a	n/a
CPS-504	Present Danger Plan	n/a		n/a
CPS-593	Permission to Screen for Reports of Abuse and Neglect	n/a			n/a	n/a

Administrative Hearings

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
DSS 03	Administrative Hearings Brochure		n/a	n/a
EA-319	Request for Administrative Hearing	n/a		n/a	n/a	n/a

Adoption and Foster Care

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
CPS	Background Information for Voluntary Termination of Parental Rights	n/a		n/a	n/a	n/a
CPS 19	Foster Care Brochure	n/a	n/a	n/a
CPS 20	Foster Care Realities	n/a	n/a	n/a
CPS 21	Foster Care Myths & Facts	n/a	n/a	n/a
CPS 22	Foster Care Handbook	n/a		n/a	n/a	n/a
CPS-506	Foster/Adoptive Parent Health Report	n/a		n/a	n/a	n/a
CPS-508	Reference Form - Adoption / Foster / Kinship Care	n/a		n/a	n/a	n/a
CPS-523	Request for Reimbursement of Adoption Home Study Form	n/a		n/a	n/a	n/a
CPS-533	Adoption Registry Form			n/a	n/a	n/a
CPS-565	Foster Parent Training & Self-Instruction	n/a		n/a	n/a	n/a

Behavioral Health

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
BH 01	Substance Use Disorder Services Brochure	n/a	n/a	n/a
BH 02	Mental Health Services Brochure	n/a	n/a	n/a
BH 03	Behavioral Health Desk Guide	n/a		n/a	n/a	n/a
BH 04	Substance Use Disorder Involuntary Commitment Process	n/a	n/a	n/a
BH 05	Intensive Methamphetamine Treatment Services	n/a	n/a	n/a
BH 10	South Dakota Community Mental Health Center Flyer	n/a	n/a	n/a
BH 11	Supported Housing Flyer	n/a	n/a	n/a
BH 12	Substance Use Disorder Services Flyer	n/a	n/a	n/a
BH 13	Juvenile Justice Reinvestment Initiative Flyer	n/a	n/a	n/a
BH 14	Substance Use Prevention Services Flyer	n/a	n/a	n/a
BH 15	Criminal Justice Initiative Flyer	n/a	n/a	n/a
BH 16	Pregnancy Alcohol Flyer	n/a	n/a	n/a
BH25	605 Strong Smartphone Wallet	n/a	n/a	n/a
BHAO01	AVOID OPIOID - How to Use Naloxone Brochure	n/a	n/a	n/a
BHAO02	AVOID OPIOID - ASAM National Practice Guideline Spiral Book	n/a	n/a	n/a
BHAO03	AVOID OPIOID - A Guide for Patients Spiral Book	n/a	n/a	n/a
BHAO04	AVOID OPIOID - Booklet	n/a	n/a	n/a
BHAO05	AVOID OPIOID - Referral Card	n/a	n/a	n/a
BHAO06	AVOID OPIOID - Project Briefs	n/a	n/a	n/a
BHAO07	AVOID OPIOID - Trifold Pocket Card	n/a	n/a	n/a
BHAO08	AVOID OPIOID - Care Coordination Business Cards	n/a	n/a	n/a
BHAO09	AVOID OPIOID - Care Coordination Brochure	n/a	n/a	n/a
BHAO10	AVOID OPIOID - Mat Brochure	n/a	n/a	n/a
BHAO11	AVOID OPIOID - Open House Resources and Tips for Realtors	n/a	n/a	n/a
BHAO12	AVOID OPIOID - Prescription Addiction Business Cards	n/a	n/a	n/a
BHAO13	AVOID OPIOID - Statewide Drop-Off Site Postcards	n/a	n/a	n/a
BHAO14	AVOID OPIOID - Resource Guide	n/a	n/a	n/a
BHAO15	AVOID OPIOID – Opioid Medications and Your Pets	n/a	n/a	n/a
BHAO16	AVOID OPIOD - Naloxone Postcard	n/a	n/a	n/a
BHAO20	AVOID OPIOID - Pill Stress Balls	n/a	n/a	n/a
BHAO21	AVOID OPIOID - Lip Balm	n/a	n/a	n/a
BHAO22	AVOID OPIOID - Vinyl Sticker	n/a	n/a	n/a
BHAO23	AVOID OPIOID - Note Pads	n/a	n/a	n/a
BHAO24	AVOID OPIOID - Pens	n/a	n/a	n/a
BHAO25	AVOID OPIOID – Notebook	n/a	n/a	n/a
BHAO26	AVOID OPIOID – Keychain	n/a	n/a	n/a
BHMC01	METH - I Need Help Rack Card	n/a	n/a	n/a
BHMC02	METH – I Want Help Rack Card	n/a	n/a	n/a
BHMC04	METH – Note Pad	n/a	n/a	n/a
BHMC05	METH – Small Magnet	n/a	n/a	n/a
BHMC06	METH – Large Magnet	n/a	n/a	n/a
BHSP01	SUICIDE PREVENTION – Business Card	n/a	n/a	n/a
BHSP02	SUICIDE PREVENTION - Strategic Plan	n/a	n/a	n/a
BHSP03	SUICIDE PREVENTION - Suicide Facts	n/a	n/a	n/a
BHSP05	SUICIDE PREVENTION - 988 The Newest Three Digit Number	n/a	n/a	n/a
BHSP06	SUICIDE PREVENTION - Strategies	n/a	n/a	n/a
BHSP16	SUICIDE PREVENTION Pen	n/a	n/a	n/a
BHSP17	SUICIDE PREVENTION Keychain	n/a	n/a	n/a
BHSPB01	Bethe1SD - Brochure	n/a	n/a	n/a
BHSPB02	Bethe1SD - Flyer	n/a	n/a	n/a
BHSPB03	Bethe1SD - Referral Card	n/a	n/a	n/a
BHSPB04	Bethe1SD - Sticker	n/a	n/a	n/a
BHSPB05	Bethe1SD - Keychain	n/a	n/a	n/a
BHSPB06	Bethe1SD - Pen	n/a	n/a	n/a
BHSPB07	Bethe1SD - Bracelet	n/a	n/a	n/a
BHSPB08	Bethe1SD - Bag	n/a	n/a	n/a
BHSPB09	Bethe1SD - Smartphone Holder	n/a	n/a	n/a
BHSPB11	Bethe1SD - Notebook	n/a	n/a	n/a
BHSPB12	Bethe1SD - Mint Tin	n/a	n/a	n/a
BHSPBKIT	Bethe1SD Toolkit	n/a	n/a	n/a
BHSPL01	LGBTQ – Always Hope Boy Poster	n/a	n/a	n/a
BHSPL02	LGBTQ – Always Help Unisex Poster	n/a	n/a	n/a
BHSPL03	LGBTQ – Always Here Girl Poster	n/a	n/a	n/a
BHSPM01	SUICIDE PREVENTION Military Poster	n/a	n/a	n/a
BHSPR01	REACH FOR LIFE Referral Card	n/a	n/a	n/a
BHSPR02	REACH FOR LIFE Flyer	n/a	n/a	n/a
BHSPR03	REACH FOR LIFE Bracelet	n/a	n/a	n/a
BHSPR04	REACH FOR LIFE Bag	n/a	n/a	n/a
BHSPR05	REACH FOR LIFE – Sticker	n/a	n/a	n/a
BHSPR06	REACH FOR LIFE – Keychain	n/a	n/a	n/a
BHSPR07	REACH FOR LIFE - Mint Tin	n/a	n/a	n/a
BHSPR08	REACH FOR LIFE - Notebook	n/a	n/a	n/a
BHSPRKIT	REACH FOR LIFE Toolkit	n/a	n/a	n/a

Child Care Services

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
CCS	Electronic Payment Exemptions	n/a	n/a	n/a
CCS	Payment Authorization 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 - Renewal Application	n/a	n/a	n/a
CCS	Pathways to Professional Development - Career Lattice Application Form	n/a	n/a	n/a
CCS 06	Child Care Assistance Program Brochure	n/a	n/a
CCS 09	SD Child Safety Seat Brochure	n/a	n/a
CCS 10	SD Child Development Associate Training Program	n/a	n/a	n/a
CCS 14	Choosing Child Care Handbook	n/a	n/a
CCS-950	Child Care Assistance Application	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
OLA 03	Office of Licensing and Accreditation Brochure	n/a	n/a	n/a
OLA-100	Background Screening Information Authorization	n/a		n/a	n/a	n/a
OLA-101	Orientation Training Verification Form	n/a		n/a	n/a	n/a
OLA-102	Application for Admission to Child Care	n/a		n/a	n/a	n/a
OLA-103	Child Care Declaration of Prior Criminal Conviction and Military History	n/a		n/a	n/a	n/a
OLA-104	Daily Attendance Form	n/a		n/a	n/a	n/a
OLA-105	Family Day Care Training Record	n/a		n/a	n/a	n/a
OLA-106	Family Day Care Immunization Affidavit	n/a		n/a	n/a	n/a
OLA-107	Medication Administration Form	n/a		n/a	n/a	n/a
OLA-108	Parent Agreement	n/a		n/a	n/a	n/a
OLA-109	Serious Incident Report Form	n/a		n/a	n/a	n/a
OLA-110	Family Day Care Helper Application	n/a		n/a	n/a	n/a
OLA-111	Family Day Care Helper Reference Form	n/a		n/a	n/a	n/a
OLA-112	Procedures for Identifying CA/N	n/a		n/a	n/a	n/a
OLA-113	FDC Emergency Preparedness Plan	n/a		n/a	n/a	n/a
OLA-114	Licensed School Age Care Programs Located in a School - Floor Plan Review	n/a		n/a	n/a	n/a
OLA-115	Floor Plan Review Process Modifications for Existing Programs	n/a		n/a	n/a	n/a
OLA-116	Floor Plan Review Process and Program Proposal	n/a		n/a	n/a	n/a
OLA-117	Family Day Care Registration Modification	n/a		n/a	n/a	n/a

Child Protection Services

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
CPS	Provider Mileage Request	n/a		n/a	n/a	n/a
CPS	Background Information for Voluntary Termination of Parental Rights	n/a		n/a	n/a	n/a
CPS	ICPC Financial and Medical Plan	n/a		n/a	n/a	n/a
CPS	Potential Placement Statement	n/a		n/a	n/a	n/a
CPS	Designated Tribal Agent Request Form	n/a		n/a	n/a	n/a
CPS	Designated Tribal Agent Request for Change of Address	n/a		n/a	n/a	n/a
CPS 01	Child Protection Services Booklet	n/a	n/a
CPS 03	Safe Havens Brochure	n/a	n/a	n/a
CPS 07	Independent Living Program Education and Training Voucher Brochure	n/a	n/a
CPS 10	Independent Living Program Brochure	n/a	n/a
CPS 13	Young Voices Brochure	n/a	n/a	n/a
CPS 14	Young Voices Handbook	n/a	n/a	n/a
CPS 23	Safe Havens Poster	n/a	n/a	n/a
CPS-100	Independent Living Program Education and Training Voucher			n/a	n/a	n/a
CPS-100A	FACIS Interstate Compact: Placement Request Form			n/a	n/a	n/a
CPS-100B	FACIS Interstate Compact: Report on Child Placement			n/a	n/a	n/a
CPS-500	Newborn Medical Report for Voluntary Termination of Parental Rights	n/a		n/a	n/a	n/a
CPS-522	Request for Payment	n/a		n/a

Child Support

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
DCS 01	Child Support Modification Handbook	n/a	n/a	n/a
DCS 02	A Guide for Teenage Parents Brochure	n/a		n/a	n/a	n/a
DCS 03	Income & Wage Withholding Brochure	n/a	n/a	n/a
DCS 04	National Medical Support Notice Brochure	n/a	n/a	n/a
DCS 06	Voluntary Paternity Establishment Handbook and Form	n/a	n/a
DCS 08	Child Support Parent Handbook	n/a	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
SE-408	Application and Agreement for Full Services	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
EA 11	Weatherization Assistance Brochure	n/a	n/a
EA 12	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	n/a	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
DSS 06	Discrimination Complaint Brochure	n/a	n/a	n/a
DSS 07	Discrimination Complaint Poster	n/a	n/a	n/a
DSS 08	Notice of Privacy Brochure	n/a	n/a
DSS 09	DSS Handbook	n/a	n/a	n/a
DSS-W9	W-9 Form	n/a	n/a	n/a
EA 01	Energy Saving Tips	n/a	n/a	n/a
EA 15	Emergency Services for SD Flyer	n/a	n/a	n/a
EA 18	Long-Term Care Partnership Brochure	n/a	n/a	n/a
EA 19	Guide to Assistance Handbook	n/a	n/a	n/a
EA-301	Economic Assistance Application	n/a
EA-310	Form for Reporting Changes	n/a	n/a

Medical Eligibility

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
EA 05	Medicare Savings Program Brochure	n/a	n/a
EA 08	Medicaid Spousal Care Handbook	n/a	n/a	n/a
EA 14	CHIP Rack Card	n/a	n/a
EA 16	Medical Assistance for Children and Families: IHS Specific	n/a	n/a	n/a
EA 23	CHIP Poster	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
EA-240D	Application for Medical Assistance for Workers with Disabilities	n/a	n/a	n/a
EA-243	Application for Chronic Renal Disease Program	n/a		n/a	n/a	n/a
EA-249	Disabled Children's Program Application	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	Medicare Savings Program Application	n/a	n/a
EA-320	Self-Employment Ledger	n/a	n/a
EA-340	Psychiatric Residential Treatment Facility Referral Form	n/a		n/a	n/a	n/a
EAFSSA	Children and Family Medical Assistance Application	n/a	n/a
MS 01	Medical Assistance Program Recipient Handbook	n/a	n/a

Medical Services

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
MS 01	Medical Assistance Program Recipient Handbook	n/a	n/a
MS 02	Provider Selection Rack Card	n/a	n/a	n/a
MS 03	Well-Child Care Brochure	n/a	n/a
MS 04	Medicaid Non-Emergency Medical Travel Brochure	n/a	n/a	n/a
MS 05	Well Visit Rack Card	n/a	n/a	n/a
MS 06	Health Home Brochure	n/a	n/a	n/a
MS 07	Premium Assistance Rack Card	n/a	n/a
MS 08	Constituent Liaison Services Brochure	n/a	n/a	n/a
MS 09	Money Follows the Person Brochure	n/a	n/a	n/a
MS 10	Medicaid Pregnancy Handbook	n/a	n/a	n/a
MS 11	Medical Equipment Recycle Reuse Brochure	n/a	n/a	n/a
MS 12	Well Child Poster	n/a	n/a	n/a
MS 13	Behavioral Health Resources	n/a	n/a	n/a
MS 15	Well Visit Poster	n/a	n/a	n/a
MS 18	Constituent Liaison Services Poster	n/a	n/a	n/a
MS-100	Recipient Forms: HIPAA Privacy Consent Form	n/a		n/a	n/a	n/a
MS-102	Provider Selection Form	n/a		n/a	n/a	n/a
MS-103	Provider Change Form	n/a		n/a	n/a	n/a
MS-112	Primary Care Provider Program Reminders - Emergency Room	n/a		n/a	n/a	n/a
MS-113	Dental At-Risk Referral Form	n/a		n/a	n/a	n/a
MS-114	South Dakota Medicaid Pre-Orthodontic Certification Form	n/a		n/a	n/a	n/a
MS-115	South Dakota Medicaid Handicapping Labio-Langual Deviations Form (HLD Index)	n/a		n/a	n/a	n/a
MS-116	Medicaid Credit Balance Report Form	n/a		n/a	n/a	n/a
MS-117	Hysterectomy Acknowledgement of Information	n/a		n/a	n/a	n/a
MS-118	Medicaid Transportation Documentation Form	n/a		n/a	n/a	n/a
MS-119	Certificate of Medical Necessity	n/a		n/a	n/a	n/a
MS-120	Transportation Exceptions Form	n/a		n/a	n/a	n/a
MS-121	Hospice Notification	n/a		n/a	n/a	n/a
MS-122	Health Home Selection and Change Form	n/a		n/a	n/a	n/a
MS-123	Health Home Decline to Participate Form	n/a		n/a	n/a	n/a
MS-124	Community Mental Health Center Health Home Referral Form	n/a		n/a	n/a	n/a
MS-125	Health Home Referral Form	n/a		n/a	n/a	n/a
MS-126	Health Home Manual Tiering Document	n/a		n/a	n/a	n/a
MS-127	Health Home Application	n/a		n/a	n/a	n/a
MS-128	Health Home Application Attestation	n/a		n/a	n/a	n/a
MS-146	Sterilization Consent Form	n/a			n/a	n/a
NEMT-952	Medicaid Non-Emergency Travel (NEMT) Payment Authorization Form	n/a			n/a	n/a
NEMT-964	Non-Emergency Medical Travel (NEMT) HIPAA Authorization	n/a		n/a	n/a	n/a
NEMT-970	NEMT Reimbursement Form \| Day Trip	n/a		n/a	n/a	n/a
NEMT-971	NEMT Reimbursement Form \| Overnight Trip	n/a		n/a	n/a	n/a
NEMT-972	NEMT Additional Lodging	n/a		n/a	n/a	n/a
NEMT-973	NEMT Appointment Verification Form	n/a		n/a	n/a	n/a
PA-100	Prior Authorization Forms: General	n/a		n/a	n/a	n/a
PA-101	Prior Authorization Forms: Durable Medical Equipment and Nutrition	n/a		n/a	n/a	n/a
PA-102	Prior Authorization Forms: Applied Behavior Analysis Therapy	n/a		n/a	n/a	n/a
PA-103	Prior Authorization Forms: Synagis	n/a		n/a	n/a	n/a
PA-104	Prior Authorization Forms: Private Duty Nursing & Extended Home Health Services	n/a		n/a	n/a	n/a
PA-105	Prior Authorization Forms: Out-of-State Services	n/a		n/a	n/a	n/a
PA-106	Prior Authorization Forms: Genetic Testing	n/a		n/a	n/a	n/a
PA-107	Prior Authorization Forms: BRCA	n/a		n/a	n/a	n/a
PA-108	Prior Authorization Form: Incontinence Supply Family Support 360 Waiver	n/a		n/a	n/a	n/a
PA-109	Prior Authorization Form: Incontinence Supply Supply HOPE Waiver	n/a		n/a	n/a	n/a
PA-110	Prior Authorization Form: Incontinence Supply ADLS Support 360 Waiver	n/a		n/a	n/a	n/a
PA-111	Prior Authorization Form: Incontinence Supply CHOICES Waiver	n/a		n/a	n/a	n/a
PA-112	Prior Authorization Form: Long Term Acute Care and Out-of-State Rehab	n/a		n/a	n/a	n/a
PA-113	Prior Authorization Form: Medical Nutrition	n/a		n/a	n/a	n/a

Parent Education

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
CPS 02	Common Sense Parenting Brochure	n/a	n/a
CPS-1053	Common Sense Parenting Annual Report Form	n/a		n/a	n/a	n/a
CPS-1054	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
ORFI-831	Estate Recovery Notification of Death Form	n/a		n/a	n/a	n/a
ORFI-832	Estate Recovery Program Petition for Limitation	n/a		n/a	n/a	n/a
ORFI-833	Report Benefit Fraud	n/a		n/a	n/a	n/a
RE 03	Estate Recovery Program Brochure	n/a	n/a	n/a
RE 04	Medicaid Liens Brochure	n/a	n/a	n/a

Supplemental Nutrition Assistance Program (SNAP)

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
EA 02	SNAP Brochure	n/a	n/a
EA 09	SNAP Shoppers Guide	n/a	n/a	n/a
EA 10	SNAP for Students	n/a	n/a	n/a
EA 22	SNAP Notice of Rights Poster	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	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	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-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

South Dakota Electronic Benefits Transfer (EBT)

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
EBT 01	EBT Client Handbook	n/a	n/a

Temporary Assistance for Needy Families (TANF)

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
CC-975	TANF Child Care Benefits Application	n/a	n/a	n/a
EA 04	TANF Brochure	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	n/a	n/a
EA-320	Self-Employment Ledger	n/a