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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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Abuse and Neglect

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
CPS 04Mandatory Reporting Brochuren/an/aspanish versionenglish version
CPS 11Central Registry Brochuren/an/aspanish versionenglish version
CPS-501Individual: Request for Screeningn/aonline versionn/an/a
CPS-502Agency: Request for Screeningn/aonline versionn/an/a
CPS-504Present Danger Plann/aonline versionn/aenglish version
CPS-593Permission to Screen for Reports of Abuse and Neglectn/aonline versionspanish versionn/a
CPS-594Declaration of Prior Criminal Conviction and Military Historyn/aonline versionn/an/a

Administrative Hearings

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
DSS 03Administrative Hearings Brochureinstructionsn/an/aenglish version
EA-319Request for Administrative Hearingn/aonline versionn/an/a

Adoption and Foster Care

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
CPSBackground Information for Voluntary Termination of Parental Rightsn/aonline versionn/an/a
CPS 09Adoption Subsidy Program n/an/an/aenglish version
CPS 19Foster Care Brochuren/an/an/aenglish version
CPS 19NFoster Care Brochure (Native American Theme)n/an/an/aenglish version
CPS 20Foster Care Realitiesn/an/an/aenglish version
CPS 20NFoster Care Realities (Native American Theme)n/an/an/aenglish version
CPS 21Foster Care Myths & Factsn/an/an/aenglish version
CPS 21NFoster Care Myths & Facts (Native American Theme)n/an/an/aenglish version
CPS 22Foster Care Handbookn/aonline versionn/an/a
CPS-506Foster/Adoptive Parent Health Reportn/aonline versionn/an/a
CPS-508Reference Form - Adoption / Foster / Kinship Caren/aonline versionn/an/a
CPS-523Request for Reimbursement of Adoption Home Study Formn/aonline versionn/an/a
CPS-533Adoption Registry Forminstructionsonline versionn/an/a
CPS-565Foster Parent Training & Self-Instructionn/aonline versionn/an/a

Behavioral Health

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
-To Order Notes to Self Materialsinstructionsn/an/an/a
-To Order Suicide Prevention Materialsinstructionsn/an/an/a
-To Order Avoid Opiod Materialsinstructionsn/an/an/a
BH 01Substance Use Disorder Services Brochuren/an/an/an/a
BH 02Mental Health Services Brochuren/an/an/aenglish version
BH 03Behavioral Health Desk Guiden/aonline versionn/an/a
BH 04Substance Use Disorder Involuntary Commitment Processn/an/an/aenglish version
BH 05Intensive Methamphetamine Treatment Servicesn/an/an/aenglish version
BH 10South Dakota Community Mental Health Center Flyern/an/an/aenglish version
BH 11Supported Housing Flyern/an/an/aenglish version
BH 12Substance Use Disorder Services Flyern/an/an/aenglish version
BH 13Juvenile Justice Reinvestment Initiative Flyern/an/an/aenglish version
BH 14Substance Use Prevention Services Flyern/an/an/aenglish version
BH 15Criminal Justice Initiative Flyern/an/an/aenglish version
BH 16Pregnancy Alcohol Flyern/an/an/aenglish version
BHAO01AVOID OPIOID - How to Use Naloxone Brochuren/an/an/aenglish version
BHAO04AVOID OPIOID - Bookletn/an/an/aenglish version
BHAO05AVOID OPIOID - Referral Cardn/an/an/aenglish version
BHAO09AVOID OPIOID - Care Coordination Brochuren/an/an/aenglish version
BHAO13AVOID OPIOID - Statewide Drop-Off Site Postcardsn/an/an/aenglish version
BHAO14AVOID OPIOID - Resource Guiden/an/an/aenglish version
BHAO22AVOID OPIOID - Vinyl Stickern/an/an/aenglish version

Child Care Services

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
CCSElectronic Payment Exemptionsn/aonline versionn/an/a
CCSPayment Authorization Formn/aonline versionn/an/a
CCSFoster Care Child Care Applicationn/aonline versionn/an/a
CCSPathways to Professional Development - Renewal Applicationn/aonline versionn/an/a
CCSPathways to Professional Development - Career Lattice Application Formn/aonline versionn/an/a
CCS 06Child Care Assistance Program Brochuren/an/aspanish versionenglish version
CCS 09SD Child Safety Seat Brochuren/an/aspanish versionenglish version
CCS 10SD Child Development Associate Training Programn/an/an/aenglish version
CCS 14Choosing Child Care Handbookn/an/aspanish versionenglish version
CCS-950Child Care Assistance Applicationn/aonline versionspanish versionenglish version
CCS-970Child Care Services Request For Paymentn/aonline versionn/aenglish version
DSS-CCSRate Declaration Formn/aonline versionn/an/a
OLA 03Office of Licensing and Accreditation Brochuren/an/an/aenglish version
OLA-100Background Screening Information Authorizationn/aonline versionn/an/a
OLA-101Orientation and Ongoing Health and Safety Training Formn/aonline versionn/an/a
OLA-102Application for Admission to Child Caren/aonline versionn/an/a
OLA-103Child Care Declaration of Prior Criminal Conviction and Military Historyn/aonline versionn/an/a
OLA-104Daily Attendance Form n/aonline versionn/an/a
OLA-105Child Care Provider Training Recordn/aonline versionn/an/a
OLA-106Immunization Affidavitn/aonline versionn/an/a
OLA-107Medication Administration Formn/aonline versionn/an/a
OLA-108Parent Agreementn/aonline versionn/an/a
OLA-109Serious Incident Report Formn/aonline versionn/an/a
OLA-110Child Care Provider Formn/aonline versionn/an/a
OLA-111Emergency Preparedness Drill Logn/aonline versionn/an/a
OLA-112Procedures for Identifying CA/N n/aonline versionn/an/a
OLA-113Sample Emergency Preparedness Plann/aonline versionn/an/a
OLA-114Licensed School Age Care Programs Located in a School - Floor Plan Reviewn/aonline versionn/an/a
OLA-116Floor Plan Review Process and Program Proposaln/aonline versionn/an/a
OLA-118Written Care Plan for a Child with Allergiesn/aonline versionn/an/a

Child Protection Services

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
CPSProvider Mileage Requestn/aonline versionn/an/a
CPSBackground Information for Voluntary Termination of Parental Rightsn/aonline versionn/an/a
CPSICPC Financial and Medical Plann/aonline versionn/an/a
CPSPotential Placement Statementn/aonline versionn/an/a
CPSDesignated Tribal Agent Request Formn/aonline versionn/an/a
CPSDesignated Tribal Agent Request for Change of Addressn/aonline versionn/an/a
CPS 01Child Protection Services Bookletn/an/aspanish versionenglish version
CPS 03Safe Havens Brochuren/an/an/aenglish version
CPS 07Independent Living Program Education and Training Voucher Brochuren/an/aspanish versionenglish version
CPS 10Independent Living Program Brochuren/an/aspanish versionenglish version
CPS 13Young Voices Brochuren/an/an/aenglish version
CPS 14Young Voices Handbookn/an/an/aenglish version
CPS 23Safe Havens Postern/an/an/aenglish version
CPS-100Independent Living Program Education and Training Voucher instructionsonline versionn/an/a
CPS-100AFACIS Interstate Compact: Placement Request Forminstructionsonline versionn/an/a
CPS-100BFACIS Interstate Compact: Report on Child Placementinstructionsonline versionn/an/a
CPS-500Newborn Medical Report for Voluntary Termination of Parental Rightsn/aonline versionn/an/a
CPS-522Request for Paymentn/aonline versionn/aenglish version

Child Support

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
DCS 01Child Support Modification Handbookn/an/an/aenglish version
DCS 02A Guide for Teenage Parents Brochuren/aonline versionn/an/a
DCS 03Income & Wage Withholding Brochuren/an/an/aenglish version
DCS 04National Medical Support Notice Brochuren/an/an/aenglish version
DCS 05Payment Options Brochuren/an/an/aenglish version
DCS 06Voluntary Paternity Establishment Handbook and Formn/an/aspanish versionenglish version
DCS 08Child Support Parent Handbookn/an/an/aenglish version
SE-405Application for Income Withholding Only Servicen/aonline versionn/an/a
SE-406Application for Location Only Servicesn/aonline versionn/an/a
SE-408Application and Agreement for Full Servicesn/aonline versionn/an/a
SE-415Petition for Modification Formn/aonline versionn/an/a
SE-431AChild Support Payment Authorization Formn/aonline versionn/an/a
SE-492Notice of Shared Medical Expensesn/aonline versionn/an/a

Energy and Weatherization

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
-South Dakota Weatherization Field Guiden/aonline versionn/an/a
EA 01Energy Saving Tipsn/an/an/aenglish version
EA 11Weatherization Assistance Brochuren/an/aspanish versionenglish version
EA 12Energy Assistance Brochuren/an/aspanish versionenglish version
EA-297Energy Assistance Applicationinstructionsn/aspanish versionenglish version
EA-298Weatherization Applicationn/an/aspanish versionenglish version
ENERGYVendor Information: Direct Depositinstructionsonline versionn/an/a
ENERGY-927Vendor Information: Vendor Claim Forminstructionsonline versionn/an/a

General Social Service Documents

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
DSS 06Discrimination Complaint Brochuren/an/an/aenglish version
DSS 07Discrimination Complaint Postern/an/an/aenglish version
DSS 08Notice of Privacy Brochuren/an/aspanish versionenglish version
DSS 09DSS Handbookn/an/an/aenglish version
DSS-W9W-9 Formn/aonline versionn/an/a
EA 15Emergency Services for SD Flyern/an/an/aenglish version
EA 18Long-Term Care Partnership Brochuren/an/an/aenglish version
EA 19Guide to Assistance Handbookn/an/aspanish versionenglish version
EA-301Economic Assistance Applicationn/aonline versionspanish versionenglish version
EA-310Form for Reporting Changesn/an/aspanish versionenglish version

Medical Eligibility

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
EA 05Medicare Savings Program Brochuren/an/aspanish versionenglish version
EA 08Medicaid Spousal Care Handbookn/an/an/aenglish version
EA 14CHIP Rack Cardn/an/aspanish versionenglish version
EA 16Medical Assistance for Children and Families: IHS Specificn/an/an/aenglish version
EA 23CHIP Postern/an/an/aenglish version
EA-208Authorization to Furnish / Release Informationn/aonline versionn/an/a
EA-211Authorization to Release Informationn/aonline versionspanish versionn/a
EA-240Application for Resource Assessment, Long Term Care or Related Medical Assistancen/an/aspanish versionenglish version
EA-265Request for Long-Term Care or Home Community Based Services Waiver Assistancen/an/aspanish versionenglish version
EA-270Medicare Savings Program Applicationn/an/aspanish versionenglish version
EA-301MAChildren and Family Medical Assistance Supplemental Application n/aonline versionn/an/a
EA-320Self-Employment Ledgern/an/aspanish versionenglish version
EA-340Psychiatric Residential Treatment Facility Referral Formn/aonline versionn/an/a
EAFSSAChildren and Family Medical Assistance Applicationn/an/aspanish versionenglish version
MS 01Medical Assistance Program Recipient Handbookn/an/aspanish versionenglish version

Medical Services

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
MS 01Medical Assistance Program Recipient Handbookn/an/aspanish versionenglish version
MS 02Provider Selection Rack Cardn/an/an/aenglish version
MS 03Well-Child Care Brochuren/an/aspanish versionenglish version
MS 04Medicaid Non-Emergency Medical Travel Brochuren/an/an/aenglish version
MS 05Well Visit Rack Card n/an/an/aenglish version
MS 06Health Home Brochuren/an/an/aenglish version
MS 07Premium Assistance Rack Cardn/an/aspanish versionenglish version
MS 08Constituent Liaison Services Brochuren/an/an/aenglish version
MS 10Medicaid Pregnancy Handbookn/an/an/aenglish version
MS 12Well Child Postern/an/an/aenglish version
MS 13Behavioral Health Resourcesn/an/an/aenglish version
MS 15Well Visit Postern/an/an/aenglish version
MS 18Constituent Liaison Services Postern/an/an/aenglish version
MS-100Recipient Forms: HIPAA Privacy Consent Formn/aonline versionn/an/a
MS-101Advanced Recipient Notice of Non-Coveragen/aonline versionn/an/a
MS-102Provider Selection Formn/aonline versionn/an/a
MS-103Provider Change Formn/aonline versionn/an/a
MS-112Primary Care Provider Program Reminders - Emergency Roomn/aonline versionn/an/a
MS-113Dental At-Risk Referral Formn/aonline versionn/an/a
MS-114South Dakota Medicaid Pre-Orthodontic Certification Formn/aonline versionn/an/a
MS-115South Dakota Medicaid Handicapping Labio-Langual Deviations Form (HLD Index)n/aonline versionn/an/a
MS-116Medicaid Credit Balance Report Formn/aonline versionn/an/a
MS-117Hysterectomy Acknowledgement of Informationn/aonline versionn/an/a
MS-118Medicaid Transportation Documentation Formn/aonline versionn/an/a
MS-120Transportation Exceptions Formn/aonline versionn/an/a
MS-121Hospice Notificationn/aonline versionn/an/a
MS-122Health Home Selection and Change Formn/aonline versionn/an/a
MS-123Health Home Decline to Participate Formn/aonline versionn/an/a
MS-124Community Mental Health Center Health Home Referral Formn/aonline versionn/an/a
MS-125Health Home Referral Formn/aonline versionn/an/a
MS-126Health Home Manual Tiering Document n/aonline versionn/an/a
MS-127Health Home Applicationn/aonline versionn/an/a
MS-128Health Home Application Attestationn/aonline versionn/an/a
MS-129Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trialsn/aonline versionn/an/a
MS-130Preadmission Screening and Resident Review (PASRR) Screening Formn/aonline versionn/an/a
MS-131Preadmission Hospital Exemption Formn/aonline versionn/an/a
MS-132ID/DD Level II Evaluation Formn/aonline versionn/an/a
MS-133Pregnancy Program Addendumn/aonline versionn/an/a
MS-134Pregnancy Program Applicationn/aonline versionn/an/a
MS-135Pregnancy Program Barriers to Care Initiatives n/aonline versionn/an/a
MS-136Pregnancy Program Overviewn/aonline versionn/an/a
MS-137Pregnancy Program Opt-In & Selection Formn/aonline versionn/an/a
MS-146Sterilization Consent Formn/aonline versionspanish versionn/a
NEMT-952Medicaid Non-Emergency Travel (NEMT) Payment Authorization Formn/aonline versionspanish versionn/a
NEMT-953NEMT Primary Care Provider/Health Home Provider Questionnairen/aonline versionn/an/a
NEMT-964Non-Emergency Medical Travel (NEMT) HIPAA Authorizationn/aonline versionn/an/a
NEMT-970NEMT Reimbursement Form | Day Tripn/aonline versionn/an/a
NEMT-971NEMT Reimbursement Form | Overnight Tripn/aonline versionn/an/a
NEMT-972NEMT Additional Lodgingn/aonline versionn/an/a
NEMT-973NEMT Appointment Verification Formn/aonline versionn/an/a
PA-100Prior Authorization Forms: Generaln/aonline versionn/an/a
PA-101Prior Authorization Forms: Durable Medical Equipment and Nutritionn/aonline versionn/an/a
PA-102Prior Authorization Forms: Applied Behavior Analysis Therapyn/aonline versionn/an/a
PA-103Prior Authorization Forms: Synagisn/aonline versionn/an/a
PA-104Prior Authorization Forms: Private Duty Nursing & Extended Home Health Servicesn/aonline versionn/an/a
PA-105Prior Authorization Forms: Out-of-State Servicesn/aonline versionn/an/a
PA-106Prior Authorization Forms: Genetic Testing n/aonline versionn/an/a
PA-107Prior Authorization Forms: BRCAn/aonline versionn/an/a
PA-108Prior Authorization Form: Incontinence Supply All Waiversn/aonline versionn/an/a
PA-112Prior Authorization Form: Long Term Acute Care and Out-of-State Rehabn/aonline versionn/an/a
PA-113Prior Authorization Form: Medical Nutritionn/aonline versionn/an/a

Parent Education

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
CPS 02Common Sense Parenting Brochuren/an/aspanish versionenglish version
CPS 05Positive Indian Parenting Brochuren/an/an/aenglish version
CPS 15Positive Indian Parenting Flyern/an/an/aenglish version
CPS-1054Common Sense Parenting Program Vouchern/aonline versionn/an/a

Recoveries and Fraud

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
ORFI-831Estate Recovery Notification of Death Formn/aonline versionn/an/a
ORFI-832Estate Recovery Program Petition for Limitationn/aonline versionn/an/a
ORFI-833Report Benefit Fraudn/aonline versionn/an/a
RE 03Estate Recovery Program Brochuren/an/an/aenglish version
RE 04Medicaid Liens Brochuren/an/an/aenglish version

Supplemental Nutrition Assistance Program (SNAP)

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
EA 02SNAP Brochuren/an/aspanish versionenglish version
EA 09SNAP Shoppers Guiden/an/an/aenglish version
EA 10SNAP for Studentsn/an/an/aenglish version
EA 22SNAP Notice of Rights Postern/an/an/aenglish version
EA-208Authorization to Furnish / Release Informationn/aonline versionn/an/a
EA-214SNAP 6 Month Report Formn/an/aspanish versionenglish version
EA-269Child Care Expense Billing Informationn/aonline versionn/an/a
EA-301SNAP Applicationn/aonline versionspanish versionenglish version
EA-305Boarding School-Institution Documentationn/aonline versionn/an/a
EA-307SNAP Exit Formn/aonline versionn/an/a
EA-307GSNAP Group Home Exit Formn/aonline versionn/an/a
EA-320Self-Employment Ledgern/an/aspanish versionenglish version
EA-324Wage Verificationn/aonline versionn/an/a
EA-347Application for Social Security Numbern/aonline versionn/an/a
OS-954Client Authorized Debit for Repayment of Overissuancen/aonline versionn/an/a

South Dakota Electronic Benefits Transfer (EBT)

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
EBT 01EBT Client Handbookn/an/aspanish versionenglish version

Temporary Assistance for Needy Families (TANF)

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
CC-975TANF Child Care Benefits Applicationn/an/an/aenglish version
EA 04TANF Brochuren/an/aspanish versionenglish version
EA-208Authorization to Furnish / Release Informationn/aonline versionn/an/a
EA-214TANF 6 Month Report Formn/an/aspanish versionenglish version
EA-231Child Support Enforcement Referraln/an/an/aenglish version
EA-320Self-Employment Ledgern/aonline versionspanish versionenglish version