Forms & Publications :: SD Dept. of Social Services

Cabinet Secretary
Matt Althoff

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:

		Some forms are available to fill out and submit online. The remaining online forms can be filled out on your computer, printed and mailed.
		You can download any form or publication on this page by clicking on the download button.
		There’s a simple “Shopping Cart” that allows you to place an order for free forms and publications. These documents will then be mailed to you at no cost.
		Instructions are available (Click on icon to view)

If you would like to order any form or publication in English, please click on Forms Only, Publications Only or All. The shopping cart will automatically default to the English version of the form or publication.

Note: Some documents are PDF files and require Adobe Acrobat to open them. If you don’t have Adobe Acrobat, click here to download the latest version.

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Service Area:

Abuse and Neglect

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
CPS-501	Individual: Request for Screening	n/a		n/a	n/a	n/a
CPS-502	Agency: Request for Screening	n/a		n/a	n/a	n/a

Administrative Hearings

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
EA-319	Request for Administrative Hearing	n/a		n/a	n/a	n/a

Adoption and Foster Care

Doc #	Document Name	Instructions	Spanish Version	English Version	Add to Cart
CPS	Background Information for Voluntary Termination of Parental Rights	n/a	n/a	n/a	n/a
CPS-506	Foster/Adoptive Parent Health Report	n/a	n/a	n/a	n/a
CPS-508	Reference Form - Adoption / Foster / Kinship Care	n/a	n/a	n/a	n/a
CPS-533	Adoption Registry Form		n/a	n/a	n/a
CPS-565	Foster Parent Training & Self-Instruction	n/a	n/a	n/a	n/a

Behavioral Health

Doc #	Document Name	Instructions	Online Version	Spanish Version
BH 01	Substance Use Disorder Services	n/a	n/a	n/a
BH 02	Mental Health Services Brochure	n/a	n/a	n/a
BH 10	South Dakota Community Mental Health Center Flyer	n/a	n/a	n/a
BH 12	Substance Use Disorder Services Flyer	n/a	n/a	n/a

Child Care Services

Doc #	Document Name	Instructions	Spanish Version	English Version	Add to Cart
CCS	Electronic Payment Exemptions	n/a	n/a	n/a	n/a
CCS	Payment Authorization Form	n/a	n/a	n/a	n/a
CCS	Foster Care Child Care Application	n/a	n/a	n/a	n/a
CCS-950	Child Care Assistance Application	n/a
CCS-970	Child Care Services Request For Payment	n/a	n/a
DSS-CCS	Rate Declaration Form	n/a	n/a	n/a	n/a
OLA-100	Background Screening Information Authorization	n/a	n/a	n/a	n/a
OLA-101	Orientation and Ongoing Health and Safety Training Form	n/a	n/a	n/a	n/a
OLA-103	Child Care Declaration of Prior Criminal Conviction and Military History	n/a	n/a	n/a	n/a

Child Protection Services

Doc #	Document Name	Instructions	Spanish Version	English Version	Add to Cart
CPS	Background Information for Voluntary Termination of Parental Rights	n/a	n/a	n/a	n/a
CPS	ICPC Financial and Medical Plan	n/a	n/a	n/a	n/a
CPS	Potential Placement Statement	n/a	n/a	n/a	n/a
CPS	Provider Mileage Request	n/a	n/a	n/a	n/a
CPS	Designated Tribal Agent Request Form	n/a	n/a	n/a	n/a
CPS	Designated Tribal Agent Request for Change of Address	n/a	n/a	n/a	n/a
CPS-100	Independent Living Program Education and Training Voucher		n/a	n/a	n/a
CPS-100A	FACIS Interstate Compact: Placement Request Form		n/a	n/a	n/a
CPS-100B	FACIS Interstate Compact: Report on Child Placement		n/a	n/a	n/a
CPS-500	Newborn Medical Report for Voluntary Termination of Parental Rights	n/a	n/a	n/a	n/a
CPS-522	Request for Payment	n/a	n/a

Child Support

Doc #	Document Name	Instructions	Spanish Version	English Version	Add to Cart
SE-405	Application for Income Withholding Only Service	n/a	n/a	n/a	n/a
SE-406	Application for Location Only Services	n/a	n/a	n/a	n/a
SE-408	Application and Agreement for Full Services	n/a	n/a	n/a	n/a
SE-415	Petition for Modification Form	n/a	n/a	n/a	n/a
SE-431A	Child Support Payment Authorization Form	n/a	n/a	n/a	n/a
SE-492	Notice of Shared Medical Expenses	n/a	n/a	n/a	n/a

General

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
EA 01	Energy Saving Tips	n/a	n/a	n/a
EA-297	Energy Assistance Application		n/a
EA-298	Weatherization Application	n/a	n/a
ENERGY	Vendor Information: Direct Deposit		n/a	n/a	n/a	n/a
ENERGY-927	Vendor Information: Vendor Claim Form			n/a	n/a	n/a

General Social Service Documents

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
DSS-W9	W-9 Form	n/a		n/a	n/a	n/a
EA-301	Economic Assistance Application	n/a
EA-310	Form for Reporting Changes	n/a	n/a

Medical Eligibility

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
EA-208	Authorization to Furnish / Release Information	n/a		n/a	n/a	n/a
EA-240	Application for Resource Assessment, Long Term Care or Related Medical Assistance	n/a	n/a
EA-265	Request for Long-Term Care or Home Community Based Services Waiver Assistance	n/a	n/a
EA-270	Medicare Savings Program Application	n/a	n/a
EA-301MA	Children and Family Medical Assistance Supplemental Application	n/a		n/a	n/a	n/a
EA-320	Self-Employment Ledger	n/a	n/a
EAFSSA	Children and Family Medical Assistance Application	n/a	n/a

Medical Services

Doc #	Document Name	Instructions	Spanish Version	English Version	Add to Cart
MS-100	Recipient Forms: HIPAA Privacy Consent Form	n/a	n/a	n/a	n/a
MS-102	Provider Selection/Change Form	n/a	n/a	n/a	n/a
MS-113	Dental At-Risk Referral Form	n/a	n/a	n/a	n/a
MS-114	South Dakota Medicaid Pre-Orthodontic Certification Form	n/a	n/a	n/a	n/a
MS-115	South Dakota Medicaid Handicapping Labio-Langual Deviations Form (HLD Index)	n/a	n/a	n/a	n/a
MS-116	Medicaid Credit Balance Report Form	n/a	n/a	n/a	n/a
MS-117	Hysterectomy Acknowledgement of Information	n/a	n/a	n/a	n/a
MS-118	Medicaid Transportation Documentation Form	n/a	n/a	n/a	n/a
MS-120	Transportation Exceptions Form	n/a	n/a	n/a	n/a
MS-123	Health Home Decline to Participate Form	n/a	n/a	n/a	n/a
MS-124	Community Mental Health Center Health Home Referral Form	n/a	n/a	n/a	n/a
MS-125	Health Home Referral Form	n/a	n/a	n/a	n/a
MS-126	Health Home Manual Tiering Document	n/a	n/a	n/a	n/a
MS-127	Health Home Application	n/a	n/a	n/a	n/a
MS-128	Health Home Application Attestation	n/a	n/a	n/a	n/a
MS-146	Sterilization Consent Form	n/a		n/a	n/a
NEMT-952	Medicaid Non-Emergency Travel (NEMT) Payment Authorization Form	n/a		n/a	n/a
PA-100	Prior Authorization Forms: General	n/a	n/a	n/a	n/a
PA-101	Prior Authorization Forms: Durable Medical Equipment and Nutrition	n/a	n/a	n/a	n/a
PA-102	Prior Authorization Forms: Applied Behavior Analysis Therapy	n/a	n/a	n/a	n/a
PA-103	Prior Authorization Forms: Synagis	n/a	n/a	n/a	n/a
PA-104	Prior Authorization Forms: Private Duty Nursing & Extended Home Health Services	n/a	n/a	n/a	n/a
PA-105	Prior Authorization Forms: Out-of-State Services	n/a	n/a	n/a	n/a
PA-106	Prior Authorization Forms: Genetic Testing	n/a	n/a	n/a	n/a
PA-107	Prior Authorization Forms: BRCA	n/a	n/a	n/a	n/a
PA-108	Prior Authorization Form: Incontinence Supply All Waivers	n/a	n/a	n/a	n/a

Parent Education

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
CPS-1054	Common Sense Parenting Program Voucher	n/a		n/a	n/a	n/a

Recoveries and Fraud

Doc #	Document Name	Instructions	Spanish Version	English Version	Add to Cart
ORFI-831	Estate Recovery Notification of Death Form	n/a	n/a	n/a	n/a
ORFI-832	Estate Recovery Program Petition for Limitation	n/a	n/a	n/a	n/a
ORFI-833	Report Benefit Fraud	n/a	n/a	n/a	n/a

Temporary Assistance for Needy Families

Doc #	Document Name	Instructions	Online Version	Spanish Version	English Version	Add to Cart
EA-208	Authorization to Furnish / Release Information	n/a		n/a	n/a	n/a
EA-214	TANF 6 Month Report Form	n/a	n/a
EA-231	Child Support Enforcement Referral	n/a		n/a	n/a	n/a
EA-320	Self-Employment Ledger	n/a