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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.

This page can help you find the information you need in the following ways:

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NOTE - our shopping cart option is currently down.
Please email your orders (include Doc# when ordering) to dss.supply@state.sd.us in the meantime.

Abuse and Neglect

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
CPS-501Individual: Request for Screeningn/aonline versionn/an/a
CPS-502Agency: Request for Screeningn/aonline versionn/an/a

Administrative Hearings

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish 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-506Foster/Adoptive Parent Health Reportn/aonline versionn/an/a
CPS-508Reference Form - Adoption / Foster / Kinship Caren/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
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 10South Dakota Community Mental Health Center Flyern/an/an/aenglish version
BH 12Substance Use Disorder Services Flyern/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-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-100Background Screening Information Authorizationn/aonline versionn/an/a
OLA-101Orientation and Ongoing Health and Safety Training Formn/aonline versionn/an/a
OLA-103Child Care Declaration of Prior Criminal Conviction and Military Historyn/aonline versionn/an/a

Child Protection Services

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
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
CPSProvider Mileage Requestn/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-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
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

General

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
EA 01Energy Saving Tipsn/an/an/aenglish 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-W9W-9 Formn/aonline versionn/an/a
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-208Authorization to Furnish / Release Informationn/aonline versionn/an/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
EAFSSAChildren and Family Medical Assistance Applicationn/an/aspanish versionenglish version

Medical Services

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish Version
MS-100Recipient Forms: HIPAA Privacy Consent Formn/aonline versionn/an/a
MS-102Provider Selection Formn/aonline versionn/an/a
MS-103Provider Change Formn/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-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-146Sterilization Consent Formn/aonline versionspanish versionn/a
NEMT-952Medicaid Non-Emergency Travel (NEMT) Payment Authorization Formn/aonline versionspanish versionn/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

Parent Education

Doc #Document NameInstructionsOnline VersionSpanish VersionEnglish 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

Temporary Assistance for Needy Families

Doc #Document NameInstructionsOnline VersionSpanish 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