Form Dss Cbh-Im - Referral For Temporary Assistance Through The South Dakota Indigent Medication Program - Department Of Social Services, State Of South Dakota Page 2
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3DSS CBH-IM-2/3/2016
Community Mental Health Center/Substance Abuse Provider:_________________________________
On Waiting List: Yes______ No_____
Appointment Date:___________________
Psychotropic/
Alcohol Cessation
Medicare
Can
Part D
Medication
Why is this medication
Milligrams/
Frequency/
generic
Co-pay
Donut
(If non-psychotropic/
prescribed?
Hole
Strength
Quantity
be used?
amount
alcohol cessation
Y/N
medication, reason
Y/N
must be indicated)
Why is this lab test ordered?
Lab test needed
Frequency
(Please list current psychotropic medications that relate to
labs being requested.)
I declare and affirm under the penalties of perjury that this information has been examined by
me, and to the best of my knowledge and belief, is in all things true and correct.
I agree to inform the South Dakota Department of Social Services, Community Behavioral Health if Medicaid,
private health insurance, or patient assistance programs are obtained anytime within the approved application year.
Consumer/Guardian Signature:___________________________________Date:_________________
Return forms (release of information, referral, drug list, and denial notice) to:
Community Behavioral Health
Phone: 605.773.3123
Kneip Building
Fax: 605.773.7076
700 Governors Drive
Toll-Free: 1.855.878.6057
Pierre, South Dakota 57501
Email: DSSBHINDMED@state.sd.us
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