Forms & Publications :: SD Dept. of Social Services

Laurie Gill
Cabinet Secretary

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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/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	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	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	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	EA-260	Statement of Earnings	Delete
1	Edit	BH-09	Indigent Medication Application	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	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	BRO/BH4	Substance Use Disorder Involuntary Commitment Process	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	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/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-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-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	PA	Prior Authorization Form: Incontinence Supply Family Support 360 Waiver	Delete
1	Edit	EA-270	Medical Savings Program Application	Delete
1	Edit	BRO/DSS4	Direct Deposit Brochure	Delete
1	Edit	BRO/RE4	Medicaid Liens Brochure	Delete
1	Edit	SE-492	Notice of Shared Medical Expenses	Delete
1	Edit	BH-13c	Family SUD Discharge Outcome Tool	Delete
1	Edit	BRO/CPS7	Independent Living Program Education and Training Voucher Brochure	Delete
1	Edit	SE408CP	Application and Agreement for Services - Custodial Parent and/or Caretaker	Delete
1	Edit	BRO/CPS15	Family Group Conferencing – My Family Meeting	Delete
1	Edit	FACIS	Interstate Compact: Placement Request Form	Delete
1	Edit	PA	Prior Authorization Form: Incontinence Supply Supply HOPE Waiver	Delete
1	Edit	BRO/MS4	Medicaid Non-Emergency Medical Travel Brochure	Delete
1	Edit	CPS-565	Foster Parent Training & Self-Instruction	Delete
1	Edit	POS/EA02	Long-Term Care Partnership Fact Sheet	Delete
1	Edit	EA-269	Child Care Expense Billing Information	Delete
1	Edit	BRO/MS1	Medical Assistance Program Recipient Handbook	Delete
1	Edit	MS-102	Provider Selection Form	Delete
1	Edit	SE-431A	Child Support Payment Authorization Form	Delete
1	Edit	BRO/DSS6	Filing a Discrimination Complaint Brochure and Form	Delete
1	Edit	BH-13d	Family MH Initial Outcome Tool	Delete
1	Edit	BRO/MS3	Well-Child Care Brochure	Delete
1	Edit		Recipient Forms: HIPAA Privacy Consent Form	Delete
1	Edit	MS	Hysterectomy Acknowledgement of Information	Delete
1	Edit	BH-11b	Adult SUD Update Outcome Tool	Delete
1	Edit	PA	Prior Authorization Forms: Genetic Testing	Delete
1	Edit	PA	Prior Authorization Form: Incontinence Supply ADLS Support 360 Waiver	Delete
1	Edit	CPS	Background Information for Voluntary Termination of Parental Rights	Delete
1	Edit	BRO/EA	Community Action Agency Handout	Delete
1	Edit	OS-954	Client Authorized Debit for Repayment of Overissuance	Delete
1	Edit	DSS-CCS	Rate Declaration Form	Delete
1	Edit	BRO/RE3	Estate Recovery Program Brochure	Delete
1	Edit	EA-319	Request for Administrative Hearing	Delete
1	Edit	BH-13e	Family MH Update Outcome Tool	Delete
1	Edit	BRO/EA8	Medicaid Spousal Care Handbook	Delete
1	Edit	CCS-970	Child Care Services Request For Payment	Delete
1	Edit	BH-17	Prevention - Accreditation Application	Delete
1	Edit	BH-11c	Adult SUD Discharge Outcome Tool	Delete
1	Edit	CCS	Pathways to Professional Development - Career Lattice Application Form	Delete
1	Edit	BRO/CPS17	Family Group Conferencing – Parents Guide	Delete
1	Edit	PA	Prior Authorization Form: Incontinence Supply CHOICES Waiver	Delete
1	Edit	EA-297	Energy Assistance Application	Delete
1	Edit	DSS	Guide to Administrative Hearings Procedure	Delete
1	Edit	CCS	Pathways to Professional Development - Renewal Application	Delete
1	Edit	Poster	Reportable Disease List Poster	Delete
1	Edit	FSSA	Children and Family Medical Assistance Application	Delete
1	Edit	MS	Certificate of Medical Necessity	Delete
1	Edit	BH-13f	Family MH Discharge Outcome Tool	Delete
1	Edit	BRO/EA5	Medicare Savings Program Brochure	Delete
1	Edit	BH-01	Federal Poverty Level Guidelines	Delete
1	Edit	BRO/DSS2	Constituent Liaison Services Brochure	Delete
1	Edit	BH-09a	Indigent Medication Update-Extension Application	Delete
1	Edit	BH-11d	Adult MH Initial Outcome Tool	Delete
1	Edit	CPS	Designated Tribal Agent Request Form	Delete
1	Edit	BRO/CPS18	Family Group Conferencing – Provider Guide	Delete
1	Edit	FACIS	Interstate Compact: Report on Child Placement	Delete
1	Edit	BRO/CCS14	Choosing Child Care Handbook	Delete
1	Edit	EA-307	SNAP Exit Form	Delete
1	Edit	CPS	ICPC Financial and Medical Plan	Delete
1	Edit	SE-406	Application for Location Only Services	Delete
1	Edit	PA	Prior Authorization Forms: Private Duty Nursing & Extended Home Health Services	Delete
1	Edit	MS	Transportation Exceptions Form	Delete
1	Edit	BRO/DCS8	Child Support Parent Handbook	Delete
1	Edit	EA-208	Authorization to Furnish / Release Information	Delete
1	Edit	BH-11e	Adult MH Update Outcome Tool	Delete
1	Edit	CPS	Background Information for Voluntary Termination of Parental Rights	Delete
1	Edit	CPS	Potential Placement Statement	Delete
1	Edit	PA	Prior Authorization Forms: Out-of State Services	Delete
1	Edit	CCS	South Dakota Child Safety Seat Distribution Program	Delete
1	Edit	EA-214	SNAP 6 Month Report Form	Delete
1	Edit	BH-03	102a Hardship Considerations	Delete
1	Edit	BRO/CPS4	Mandatory Reporting of Child Abuse & Neglect Brochure	Delete