Form Dss Cbh-Im - Referral For Temporary Assistance Through The South Dakota Indigent Medication Program - Department Of Social Services, State Of South Dakota

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DSS CBH-IM-2/3/2016
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 related laboratory
Entire application must be completed.
work.
Please print clearly.
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 ________
If no, are you actively seeking employment? Yes___ No___ If no, why not?___________________________
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 ___Have not applied yet: ____
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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