Forms & Publications :: SD Dept. of Social Services

Laurie Gill
Cabinet Secretary

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Below you will find the selected forms and/or publications for this order. You will need to indicate the quantity you want to receive in the box next to the document number. After you have entered the quantity, click "Update" in the previous box. If you wish to remove a form or publication, simply click on the link that states "Delete." Once you have entered the quantity for each form or publication, click the "Proceed" button at the bottom.

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Copies	Edit the Number of Copies	Document Number	Document Name	Delete
1	Edit	EA-208	Authorization to Furnish / Release Information	Delete
1	Edit	EA-265	Request for Long-Term Care or Home Community Based Services Waiver Assistance	Delete
1	Edit	BRO/EA19	Guide to Assistance Handbook	Delete
1	Edit	BRO/DSS8	Notice of Privacy Brochure	Delete
1	Edit	BRO/EBT1	EBT Client Handbook	Delete
1	Edit	EA-214	TANF 6 Month Report Form	Delete
1	Edit	CCS	Electronic Payment Exemptions	Delete
1	Edit	CPS	Placement Resource Monthly Reporting Form Ages 14 and older	Delete
1	Edit	BRO/DSS3	Administrative Hearings Brochure	Delete
1	Edit	MISC/BH1	South Dakota Community Mental Health Center Flyer	Delete
1	Edit	-	South Dakota Medicaid Handicapping Labio-Langual Deviations Form (HLD Index)	Delete
1	Edit	BRO/CPS10	Independent Living Program Brochure	Delete
1	Edit	EA-320	Self-Employment Ledger	Delete
1	Edit	BH-05	Hardship Considerations Refusal	Delete
1	Edit	MS-146	Sterilization Consent Form	Delete
1	Edit	BRO/EA11	Weatherization Assistance Brochure	Delete
1	Edit	BRO/DCS3	Income and Wage Withholding Brochure - Information for SD Employers, Financial Institutions, and Other Payors of Income	Delete
1	Edit	BRO/EA1	Energy Saving Tips	Delete
1	Edit	PA	Prior Authorization Forms: Synagis	Delete
1	Edit	EA-240D	Application for Medical Assistance for Workers with Disabilities	Delete
1	Edit	CPS-566	Foster Parent Evaluation	Delete
1	Edit	BRO/CPS11	Central Registry of Child Abuse & Neglect	Delete
1	Edit	CCS	Payment Authorization Form	Delete
1	Edit	CPS	Placement Resource Monthly Reporting Form Ages 5-13	Delete
1	Edit	MISC/BH3	Substance Use Disorder Services Flyer	Delete
1	Edit	Rec and Fraud	Estate Recovery Program Petition for Limitation	Delete
1	Edit	BRO/EA14	Medical Assistance for Children and Families	Delete
1	Edit	EA-345A	Affidavit for SNAP Work Registrants (Employment & Training)	Delete
1	Edit	BH-06	3rd Party Release of Information (ROI)	Delete
1	Edit	CCS-950	Child Care Assistance Application	Delete
1	Edit	BRO/DCS4	National Medical Support Notice Brochure - An Employers Guide	Delete
1	Edit	MS	Medicaid Non-Emergency Travel (NEMT) Payment Authorization Form	Delete
1	Edit	BH-18	Substance Use Disorder High Intensity Referral Form	Delete
1	Edit	CC-975	TANF Child Care Benefits Application	Delete
1	Edit	DSS-CPS	Safe Havens Poster	Delete
1	Edit	EA-320	Self-Employment Ledger	Delete
1	Edit	BH-12a	Youth SUD Initial Outcome Tool	Delete
1	Edit	OS-950	Recipient Forms: Medicaid Non-Emergency Medical Travel Form	Delete
1	Edit	CPS-506	Foster/Adoptive Parent Health Report	Delete
1	Edit	BH-07	Mental Health - Accreditation Application	Delete
1	Edit	BRO/DCS2	Teenage Parents Guide - How to Establish Paternity and Financial Support for your Child	Delete
1	Edit	PA	Prior Authorization Forms: Applied Behavior Analysis Therapy	Delete
1	Edit	CC-975	TANF Child Care Benefits Application	Delete
1	Edit	EA-260	Statement of Earnings	Delete
1	Edit	BH-09	Indigent Medication Application	Delete
1	Edit	Poster	Recommendations for Exclusion from the Child Care Setting Poster	Delete
1	Edit	EA-240	Application for Resource Assessment, Long Term Care or Related Medical Assistance	Delete
1	Edit	BRO/CPS3	Safe Havens Brochure	Delete
1	Edit	BH-12b	Youth SUD Update Outcome Tool	Delete
1	Edit	EA-269	Child Care Expense Billing Information	Delete
1	Edit	DSS-ORFI-831	Estate Recovery Notification of Death Form	Delete
1	Edit	Poster	Constituent Liaison Services Poster	Delete
1	Edit	BH-08	Mental Health - IMPACT Application	Delete
1	Edit	BRO/DCS6	Voluntary Paternity Establishment Handbook and Form	Delete
1	Edit	EA-301MA	Children and Family Medical Assistance Supplemental Application	Delete
1	Edit	BH-12d	Youth MH Initial Outcome Tool	Delete
1	Edit	MS	Hospice Notification	Delete
1	Edit	BRO/CPS2	Common Sense Parenting Brochure	Delete
1	Edit	Poster	CHIP Poster	Delete
1	Edit	BRO/CCS6	Child Care Assistance Program Brochure	Delete
1	Edit	CPS	Provider Mileage Request	Delete
1	Edit	BRO/EA4	TANF Work Program Brochure	Delete
1	Edit	CCS-964	Child Care Declaration of Prior Criminal Conviction and Military History	Delete
1	Edit	BH-12c	Youth SUD Discharge Outcome Tool	Delete
1	Edit	BRO/CPS1	Child Protection Services Booklet	Delete
1	Edit	ENERGY	Vendor Information: Direct Deposit	Delete
1	Edit	Poster	CHIP Poster	Delete
1	Edit	BRO/EA16	Medical Assistance for Children and Families: IHS Specific	Delete
1	Edit	EA-324	Wage Verification	Delete
1	Edit	BRO/RE1	Stop Benefit Fraud Brochure	Delete
1	Edit	CPS-533	Adoption Registry Form	Delete
1	Edit	BH-12e	Youth MH Update Outcome Tool	Delete
1	Edit	BRO/BH4	Substance Use Disorder Involuntary Commitment Process	Delete
1	Edit	EA-345	Affidavit for SNAP Work Registrants	Delete
1	Edit	BH-11	Behavioral Health Treatment Outcomes Program Manual	Delete
1	Edit	CPS-500	Newborn Medical Report for Voluntary Termination of Parental Rights	Delete
1	Edit	BRO/DSS9	DSS Handbook	Delete
1	Edit	CPS-508	Reference Form - Adoption / Foster / Kinship Care	Delete
1	Edit	BRO/EA9	SNAP Shoppers Guide	Delete
1	Edit	SE-405	Application for Income Withholding Only Service	Delete
1	Edit	BH-12f	Youth MH Discharge Outcome Tool	Delete
1	Edit	CPS-549	Request for Screening for Substantial Reports of Abuse and Neglect (unregistered family day care providers ONLY)	Delete
1	Edit	OS-964	Non-Emergency Medical Travel HIPAA Authorization	Delete
1	Edit	BRO/CCS3	Registration & Licensure of Child Care Environments	Delete
1	Edit	EA-347	Application for Social Security Number	Delete
1	Edit	BRO/BH5	Intensive Methamphetamine Treatment Services	Delete
1	Edit	BRO/CPS9	Adoption Subsidy Handbook	Delete
1	Edit	BRO/EA2	SNAP Brochure	Delete
1	Edit	CPS	Independent Living Program Education and Training Voucher	Delete
1	Edit	CCS	Orientation Training Verification Form	Delete
1	Edit	BH-13a	Family SUD Initial Outcome Tool	Delete
1	Edit	SE408NCP	Application and Agreement for Services - Non-Custodial Parent	Delete
1	Edit	CPS-522	Request for Payment	Delete
1	Edit	CPS	Designated Tribal Agent Request for Change of Address	Delete
1	Edit	CPS-593	Permission to Screen for Reports of Abuse or Neglect	Delete
1	Edit	PA	Prior Authorization Forms: BRCA	Delete
1	Edit	CPS-504	Present Danger Plan	Delete
1	Edit	EA-320	Self-Employment Ledger	Delete
1	Edit	EA-310	Form for Reporting Changes	Delete
1	Edit	EA-305	Boarding School-Institution Documentation	Delete
1	Edit	Rec and Fraud	Stop Benefit Fraud Insert	Delete
1	Edit	BRO/EA10	SNAP for Students	Delete
1	Edit	BRO/EA12	Energy Assistance Brochure	Delete
1	Edit	BRO/MS1	Medical Assistance Program Recipient Handbook	Delete
1	Edit	EA-301	SNAP Application	Delete
1	Edit	BH-13b	Family SUD Update Outcome Tool	Delete
1	Edit	CPS-594	Declaration of Prior Criminal Conviction & Military History	Delete
1	Edit	EA-298	Weatherization Application	Delete
1	Edit	BRO/EA18	Long-Term Care Partnership Brochure	Delete
1	Edit	PA	Prior Authorization Forms: Durable Medical Equipment and Nutrition	Delete
1	Edit	BH-14	Substance Abuse - Accreditation Application	Delete
1	Edit	SE-415	Petition for Modification Form	Delete
1	Edit	MS	Medicaid Transportation Documentation Form	Delete
1	Edit	PA	Prior Authorization Form: Incontinence Supply Family Support 360 Waiver	Delete
1	Edit	EA-270	Medical Savings Program Application	Delete