Forms & Publications :: SD Dept. of Social Services

Cabinet Secretary
Laurie R. Gill

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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	BRODSS08	Notice of Privacy Brochure	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	BRODSS03	Administrative Hearings Brochure	Delete
1	Edit	FLYRBH01	South Dakota Community Mental Health Center Flyer	Delete
1	Edit	-	South Dakota Medicaid Handicapping Labio-Langual Deviations Form (HLD Index)	Delete
1	Edit	MS-146	Sterilization Consent Form	Delete
1	Edit	BROEA01	Energy Saving Tips	Delete
1	Edit	PA	Prior Authorization Forms: Synagis	Delete
1	Edit	CCS	Payment Authorization Form	Delete
1	Edit	CPS	Placement Resource Monthly Reporting Form Ages 5-13	Delete
1	Edit	Rec and Fraud	Estate Recovery Program Petition for Limitation	Delete
1	Edit	EA-345A	Affidavit for SNAP Work Registrants (Employment & Training)	Delete
1	Edit	CCS-950	Child Care Assistance Application	Delete
1	Edit	EA-320	Self-Employment Ledger	Delete
1	Edit	CPS-506	Foster/Adoptive Parent Health Report	Delete
1	Edit	PA	Prior Authorization Forms: Applied Behavior Analysis Therapy	Delete
1	Edit	EA-260	Statement of Earnings	Delete
1	Edit	BROCPS03	Safe Havens Brochure	Delete
1	Edit	EA-269	Child Care Expense Billing Information	Delete
1	Edit	BROCPS13	Young Voices Brochure	Delete
1	Edit	BROCCS06	Child Care Assistance Program Brochure	Delete
1	Edit	CPS	Provider Mileage Request	Delete
1	Edit	CCS-964	Child Care Declaration of Prior Criminal Conviction and Military History	Delete
1	Edit	HDBKCPS01	Child Protection Services Booklet	Delete
1	Edit	FLYRBH04	Juvenile Justice Reinvestment Initiative Flyer	Delete
1	Edit	BROEA16	Medical Assistance for Children and Families: IHS Specific	Delete
1	Edit	BROBH04	Substance Use Disorder Involuntary Commitment Process	Delete
1	Edit	EA-249	Disabled Children's Program Application	Delete
1	Edit	CPS-500	Newborn Medical Report for Voluntary Termination of Parental Rights	Delete
1	Edit	HDBKDSS09	DSS Handbook	Delete
1	Edit	FLYRBH05	Substance Use Prevention Services Flyer	Delete
1	Edit	CPS-508	Reference Form - Adoption / Foster / Kinship Care	Delete
1	Edit	CPS-549	Request for Screening for Substantial Reports of Abuse and Neglect (unregistered family day care providers ONLY)	Delete
1	Edit	FLYRBH06	Criminal Justice Initiative Flyer	Delete
1	Edit	CPS	Independent Living Program Education and Training Voucher	Delete
1	Edit	CCS	Orientation Training Verification Form	Delete
1	Edit	SE408NCP	Application and Agreement for Services - Non-Custodial Parent	Delete
1	Edit	BROMS02	Provider Selection Rack Card	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	EA-320	Self-Employment Ledger	Delete
1	Edit	BROHSC01	Mental Health Wellness and Recovery Phone Apps Brochure	Delete
1	Edit	EA-301	SNAP Application	Delete
1	Edit	EA-298	Weatherization Application	Delete
1	Edit	BROEA11	Weatherization Assistance Brochure	Delete
1	Edit	PA	Prior Authorization Forms: Durable Medical Equipment and Nutrition	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	BROCPS07	Independent Living Program Education and Training Voucher Brochure	Delete
1	Edit	BROEA12	Energy Assistance Brochure	Delete
1	Edit	SE408CP	Application and Agreement for Services - Custodial Parent and/or Caretaker	Delete
1	Edit	FACIS	Interstate Compact: Placement Request Form	Delete
1	Edit	PA	Prior Authorization Form: Incontinence Supply Supply HOPE Waiver	Delete
1	Edit	FLYREA02	Long-Term Care Partnership Fact Sheet	Delete
1	Edit	EA-269	Child Care Expense Billing Information	Delete
1	Edit	MS-102	Provider Selection Form	Delete
1	Edit	SE-431A	Child Support Payment Authorization Form	Delete
1	Edit	BROMS03	Well-Child Care Brochure	Delete
1	Edit		Recipient Forms: HIPAA Privacy Consent Form	Delete
1	Edit	MS	Hysterectomy Acknowledgement of Information	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	OS-954	Client Authorized Debit for Repayment of Overissuance	Delete
1	Edit	BRORE03	Estate Recovery Program Brochure	Delete
1	Edit	CCS-970	Child Care Services Request For Payment	Delete
1	Edit	CCS	Pathways to Professional Development - Career Lattice Application Form	Delete
1	Edit	CCS	Pathways to Professional Development - Renewal Application	Delete
1	Edit	FSSA	Children and Family Medical Assistance Application	Delete
1	Edit	BROEA05	Medicare Savings Program Brochure	Delete
1	Edit	CPS	Designated Tribal Agent Request Form	Delete
1	Edit	BROBH03	Quick Reference Guide	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	MS	Transportation Exceptions Form	Delete
1	Edit	BRODCS08	Child Support Parent Handbook	Delete
1	Edit	EA-208	Authorization to Furnish / Release Information	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	EA-214	SNAP 6 Month Report Form	Delete
1	Edit	BROCPS04	Mandatory Reporting of Child Abuse & Neglect Brochure	Delete
1	Edit	Rec and Fraud	Casualty Settlement Report Form	Delete
1	Edit	EA-301	Economic Assistance Application	Delete
1	Edit	CPS	Placement Resource Monthly Reporting Form Ages 0-4	Delete
1	Edit	-	South Dakota Medicaid Pre-Orthodontic Certification Form	Delete
1	Edit	BROEA19	Guide to Assistance Handbook	Delete
1	Edit	HDBKEBT01	EBT Client Handbook	Delete
1	Edit	BROCPS10	Independent Living Program Brochure	Delete
1	Edit	EA-320	Self-Employment Ledger	Delete
1	Edit	BRODCS03	Income and Wage Withholding Brochure - Information for SD Employers, Financial Institutions, and Other Payors of Income	Delete
1	Edit	EA-240D	Application for Medical Assistance for Workers with Disabilities	Delete
1	Edit	CPS-566	Foster Parent Evaluation	Delete
1	Edit	BROCPS11	Central Registry of Child Abuse & Neglect	Delete
1	Edit	FLYRBH03	Substance Use Disorder Services Flyer	Delete
1	Edit	BROEA14	CHIP Rack Card	Delete
1	Edit	BRODCS04	National Medical Support Notice Brochure - An Employers Guide	Delete
1	Edit	MS	Medicaid Non-Emergency Travel (NEMT) Payment Authorization Form	Delete
1	Edit	CC-975	TANF Child Care Benefits Application	Delete
1	Edit	POSCPS03	Safe Havens Poster	Delete
1	Edit	OS-950	Recipient Forms: Medicaid Non-Emergency Medical Travel Form	Delete
1	Edit	HDBKCPS14	Young Voices Handbook	Delete
1	Edit	CC-975	TANF Child Care Benefits Application	Delete
1	Edit	EA-240	Application for Resource Assessment, Long Term Care or Related Medical Assistance	Delete
1	Edit	DSS-ORFI-831	Estate Recovery Notification of Death Form	Delete
1	Edit	POSMS08	Constituent Liaison Services Poster	Delete
1	Edit	HDBKDCS06	Voluntary Paternity Establishment Handbook and Form	Delete
1	Edit	EA-301MA	Children and Family Medical Assistance Supplemental Application	Delete
1	Edit	MS	Hospice Notification	Delete
1	Edit	BROCPS02	Common Sense Parenting Brochure	Delete
1	Edit	BROEA04	TANF Work Program Brochure	Delete
1	Edit	ENERGY	Vendor Information: Direct Deposit	Delete
1	Edit	POSEA03	CHIP Poster	Delete
1	Edit	EA-324	Wage Verification	Delete
1	Edit	CPS-533	Adoption Registry Form	Delete
1	Edit	EA-345	Affidavit for SNAP Work Registrants	Delete
1	Edit	BROEA09	SNAP Shoppers Guide	Delete
1	Edit	SE-405	Application for Income Withholding Only Service	Delete
1	Edit	OS-964	Non-Emergency Medical Travel HIPAA Authorization	Delete
1	Edit	BROCCS03	Registration & Licensure of Child Care Environments	Delete
1	Edit	EA-347	Application for Social Security Number	Delete
1	Edit	BROBH05	Intensive Methamphetamine Treatment Services	Delete