Doc # | Document Name | Instructions | Online Version | Spanish Version | English Version |
---|
- | To Order Notes to Self Materials | | n/a | n/a | n/a |
- | To Order Suicide Prevention Materials | | n/a | n/a | n/a |
- | To Order Avoid Opiod Materials | | n/a | n/a | n/a |
BH 01 | Substance Use Disorder Services Brochure | n/a | 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 |
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 | |
BHAO01 | AVOID OPIOID - How to Use Naloxone Brochure | 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 | |
BHAO09 | AVOID OPIOID - Care Coordination Brochure | 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 | |
BHAO22 | AVOID OPIOID - Vinyl Sticker | n/a | n/a | n/a | |
Doc # | Document Name | Instructions | Online Version | Spanish Version | English Version |
---|
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 |
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 |
OLA-101 | Orientation and Ongoing Health and Safety Training Form | n/a | | n/a | n/a |
OLA-102 | Application for Admission to Child Care | n/a | | n/a | n/a |
OLA-103 | Child Care Declaration of Prior Criminal Conviction and Military History | n/a | | n/a | n/a |
OLA-104 | Daily Attendance Form | n/a | | n/a | n/a |
OLA-105 | Child Care Provider Training Record | n/a | | n/a | n/a |
OLA-106 | Immunization Affidavit | n/a | | n/a | n/a |
OLA-107 | Medication Administration Form | n/a | | n/a | n/a |
OLA-108 | Parent Agreement | n/a | | n/a | n/a |
OLA-109 | Serious Incident Report Form | n/a | | n/a | n/a |
OLA-110 | Child Care Provider Form | n/a | | n/a | n/a |
OLA-111 | Emergency Preparedness Drill Log | n/a | | n/a | n/a |
OLA-112 | Procedures for Identifying CA/N | n/a | | n/a | n/a |
OLA-113 | Sample Emergency Preparedness Plan | 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 |
OLA-116 | Floor Plan Review Process and Program Proposal | n/a | | n/a | n/a |
OLA-118 | Written Care Plan for a Child with Allergies | n/a | | n/a | n/a |
Doc # | Document Name | Instructions | Online Version | Spanish Version | English Version |
---|
CPS | Provider Mileage Request | n/a | | 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 | 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 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 |
CPS-100A | FACIS Interstate Compact: Placement Request Form | | | n/a | n/a |
CPS-100B | FACIS Interstate Compact: Report on Child Placement | | | n/a | n/a |
CPS-500 | Newborn Medical Report for Voluntary Termination of Parental Rights | n/a | | n/a | n/a |
CPS-522 | Request for Payment | n/a | | n/a | |
Doc # | Document Name | Instructions | Online Version | Spanish Version | English Version |
---|
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 |
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 05 | Payment Options 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 |
Doc # | Document Name | Instructions | Online Version | Spanish Version | English Version |
---|
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 | n/a |
EA-211 | Authorization to Release Information | n/a | | | n/a |
EA-240 | Application for Resource Assessment, Long Term Care or Related Medical Assistance | n/a | n/a | | |
EA-265 | Request for Long-Term Care or Home Community Based Services Waiver Assistance | n/a | n/a | | |
EA-270 | Medicare Savings Program Application | n/a | n/a | | |
EA-301MA | Children and Family Medical Assistance Supplemental Application | n/a | | 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 |
EAFSSA | Children and Family Medical Assistance Application | n/a | n/a | | |
MS 01 | Medical Assistance Program Recipient Handbook | n/a | n/a | | |
Doc # | Document Name | Instructions | Online Version | Spanish Version | English Version |
---|
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 10 | Medicaid Pregnancy Handbook | 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 |
MS-101 | Advanced Recipient Notice of Non-Coverage | n/a | | n/a | n/a |
MS-102 | Provider Selection Form | n/a | | n/a | n/a |
MS-103 | Provider Change Form | n/a | | n/a | n/a |
MS-112 | Primary Care Provider Program Reminders - Emergency Room | n/a | | n/a | n/a |
MS-113 | Dental At-Risk Referral Form | n/a | | n/a | n/a |
MS-114 | South Dakota Medicaid Pre-Orthodontic Certification Form | n/a | | n/a | n/a |
MS-115 | South Dakota Medicaid Handicapping Labio-Langual Deviations Form (HLD Index) | n/a | | n/a | n/a |
MS-116 | Medicaid Credit Balance Report Form | n/a | | n/a | n/a |
MS-117 | Hysterectomy Acknowledgement of Information | n/a | | n/a | n/a |
MS-118 | Medicaid Transportation Documentation Form | n/a | | n/a | n/a |
MS-120 | Transportation Exceptions Form | n/a | | n/a | n/a |
MS-121 | Hospice Notification | n/a | | n/a | n/a |
MS-122 | Health Home Selection and Change Form | n/a | | n/a | n/a |
MS-123 | Health Home Decline to Participate Form | n/a | | n/a | n/a |
MS-124 | Community Mental Health Center Health Home Referral Form | n/a | | n/a | n/a |
MS-125 | Health Home Referral Form | n/a | | n/a | n/a |
MS-126 | Health Home Manual Tiering Document | n/a | | n/a | n/a |
MS-127 | Health Home Application | n/a | | n/a | n/a |
MS-128 | Health Home Application Attestation | n/a | | n/a | n/a |
MS-129 | Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trials | n/a | | n/a | n/a |
MS-130 | Preadmission Screening and Resident Review (PASRR) Screening Form | n/a | | n/a | n/a |
MS-131 | Preadmission Hospital Exemption Form | n/a | | n/a | n/a |
MS-132 | ID/DD Level II Evaluation Form | n/a | | n/a | n/a |
MS-133 | Pregnancy Program Addendum | n/a | | n/a | n/a |
MS-134 | Pregnancy Program Application | n/a | | n/a | n/a |
MS-135 | Pregnancy Program Barriers to Care Initiatives | n/a | | n/a | n/a |
MS-136 | Pregnancy Program Overview | n/a | | n/a | n/a |
MS-137 | Pregnancy Program Opt-In & Selection Form | n/a | | n/a | n/a |
MS-146 | Sterilization Consent Form | n/a | | | n/a |
NEMT-952 | Medicaid Non-Emergency Travel (NEMT) Payment Authorization Form | n/a | | | n/a |
NEMT-953 | NEMT Primary Care Provider/Health Home Provider Questionnaire | n/a | | n/a | n/a |
NEMT-964 | Non-Emergency Medical Travel (NEMT) HIPAA Authorization | n/a | | n/a | n/a |
NEMT-970 | NEMT Reimbursement Form | Day Trip | n/a | | n/a | n/a |
NEMT-971 | NEMT Reimbursement Form | Overnight Trip | n/a | | n/a | n/a |
NEMT-972 | NEMT Additional Lodging | n/a | | n/a | n/a |
NEMT-973 | NEMT Appointment Verification Form | n/a | | n/a | n/a |
PA-100 | Prior Authorization Forms: General | n/a | | n/a | n/a |
PA-101 | Prior Authorization Forms: Durable Medical Equipment and Nutrition | n/a | | n/a | n/a |
PA-102 | Prior Authorization Forms: Applied Behavior Analysis Therapy | n/a | | n/a | n/a |
PA-103 | Prior Authorization Forms: Synagis | n/a | | n/a | n/a |
PA-104 | Prior Authorization Forms: Private Duty Nursing & Extended Home Health Services | n/a | | n/a | n/a |
PA-105 | Prior Authorization Forms: Out-of-State Services | n/a | | n/a | n/a |
PA-106 | Prior Authorization Forms: Genetic Testing | n/a | | n/a | n/a |
PA-107 | Prior Authorization Forms: BRCA | n/a | | n/a | n/a |
PA-108 | Prior Authorization Form: Incontinence Supply All Waivers | 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 |
PA-113 | Prior Authorization Form: Medical Nutrition | n/a | | n/a | n/a |