Form Sd Eform - 1744 V5 - Referral For Temporary Assistance Through The South Dakota Indigent Medication Program - Department Of Social Services, State Of South Dakota
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SD EForm - 1744
V5
HELP
Referral for Temporary Assistance through the South Dakota Indigent
Medication Program
The Department of Social Services, Community Behavioral Health will use this information to
determine eligibility for temporary coverage of psychotropic/alcohol cessation medications and/or
Please print clearly.
Entire application must be completed.
related laboratory work.
Date: __________________Person assisting with this form/Title: ____________________________________
Client Name: ________________________________________________________________________________
First
MI
Last
Address: __________________________________________
Date of Birth: _______________________
City/State/Zip: ____________________________________________ Soc. Sec. #:__________________________
Telephone Number: ________________________________
Sex: Male_______
Female________
Married _______ Single _______Widowed______ Separated ____________# People in household_____________
Diagnosis: ___________________________________________________________________________________
Last hospitalization for mental illness and/or alcohol dependence:
Date: _______________________________________Where:___________________________________________
Income & Insurance
Are you currently employed? Yes________ Hrs/week _________
No___________ Volunteer work ________
No____ If no, why not? _________________________
If “No” are you actively seeking employment? Yes____
Are you currently incarcerated? Yes____ No____ If yes, where and release date?____________________________
Yearly Household Income: Self $______________________ Spouse $___________________________
SSI/SSDI Application Status: Applied/Pending______ Denied_______ Appealed_______ Approved ______
Supplemental Security Income (check on the first of the month): $___________________________________
rd
Soc. Sec. Disability Insurance (check on the 3
of the month): $______________________________________
Have you applied for Medicaid or health insurance through the Federal Exchange (healthcare.gov)? Yes____ No____
Have you applied for any Patient Assistance Programs? Yes_____ No _____
If yes, which ones? ___________________________________________________________________________
Do you currently have any insurance plan that pays for prescription drugs including Medicaid:
Yes_____
No _____
Do you have Medicare Benefits? Part A Yes ____ No____ Part B Yes____ No____
Part D Yes ____ No ____
Have you applied for Medicare Part D insurance for your prescriptions? Yes ___ No ____ If no, why not? _____________
If yes, what plan are you on? __________________________________________________
Pharmacy:
Pharmacy: _____________________________________________________________________________
Address: ______________________________________City/State/Zip: ___________________________
Phone: ________________________________________ Fax (if known):___________________________
Health care center where lab work is to be done:
Health care center: ________________________________________________________________________
Address: ______________________________________City/State/Zip: ___________________________
Phone: ________________________________________ Fax (if known):___________________________
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