Form Dss Cbh-Im - Referral For Temporary Assistance Through The South Dakota Indigent Medication Program - Department Of Social Services, State Of South Dakota Page 3
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3DSS CBH-IM-2/3/2016
DEPARTMENT OF SOCIAL SERVICES, COMMUNITY BEHAVIORAL HEALTH
AUTHORIZATION TO EXCHANGE INFORMATION
I hereby authorize the Department of Social Services, Community Behavioral Health to release and/or
exchange information both orally and in writing, with respect to diagnosis and course of treatment of my
mental illness and/or alcohol dependence with any Community Mental Health Center/Substance Abuse
Provider, pharmacy, medical provider, provider of laboratory services, and/or pharmaceutical
programs.
Consumer/Guardian Signature
DATE __________
I acknowledge that the Department of Social Services, Community Behavioral Health will pay for my
psychotropic/alcohol cessation medications and/or related lab costs on a time-limited basis, as determined
by the Department of Social Services, Community Behavioral Health.
I understand the above criteria and the terms/conditions of my participation in the program offered
through the Department of Social Services, Community Behavioral Health.
I agree to the following as terms/conditions of this medication/laboratory funding agreement:
•
I will take all psychotropic/alcohol cessation medications as prescribed.
•
I will be responsible to cover the cost of replacing lost or damaged medications.
•
I will not sell, give away or otherwise distribute medications intended for personal use.
•
I will keep all scheduled psychiatric/substance abuse provider appointments and comply with treatment.
•
I will develop a plan for long term needs as state funding is limited.
•
I understand that funding may end with no greater than a 30 day notice.
•
I will continue to exhaust all other funding resources.
•
I authorize the exchange/release of relevant and necessary medical/psychiatric/substance abuse information to the
Department of Social Services, Community Behavioral Health.
•
I agree to inform the Department of Social Services, Community Behavioral Health if Medicaid, private health
insurance, patient assistance programs, and/or my financial status would otherwise change.
•
I understand that failure to comply with the above-based requirements will result in my termination from the
program and/or repayment.
•
I understand that if this application is not complete or correct, this application will be destroyed.
•
I understand that this application will be effective one year from the date originally signed.
•
I understand that I may revoke my consent at any time and that revocation is effective upon receipt, except to the
extent previously relied upon.
Consumer/Guardian Signature
DATE _________
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