Sd Eform - 2391 V2 - Indigent Medication Update/extension
Download a blank fillable Sd Eform - 2391 V2 - Indigent Medication Update/extension in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Sd Eform - 2391 V2 - Indigent Medication Update/extension with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Indigent Medication Update/Extension Form 1.0
Complete and use the button at the end to print for mailing.
SD EForm - 2391
V2
HELP
Referral for Continued 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 continued temporary coverage of psychotropic/alcohol cessation medications and/or related
laboratory work. Entire application must be completed. Please print clearly.
Current Date: _______________________ Date of Original Application (if known):______________________
_______Update______1st Extension______2nd or more (must be staffed with Division prior to reauthorization)
Client Name: __________________________________________DOB________________________________
Person assisting with this form & Agency: _______________________________________________________
Income & Insurance
Are you currently employed? Yes________ No___________ Volunteer work ________ Hrs/week _________
If “No” are you actively seeking employment? Yes________ No_________ If no, why not? __________________________
Yearly Household Income, including SSI/SSDI: _____________________________________________________________
SSI/SSDI Application Status: Applied/Pending______ Denied______Appealed_____ Have Not Applied Yet _____
Approved ______Effective Date _________
Do you currently have any insurance plan that pays for prescription drugs: 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 ________
Are you currently pursuing alternate funding options? (Required for continued assistance)
Prescription Assistance______ Insurance/Medicaid_______ Self-Pay/Budgeting_______ Samples______
Medication/ Lab Requested
Milligrams/
Frequency/
Update/
Reason for Extension
Strength
Quantity
Extension
Pharmacy/Laboratory:
Name: ___________________________________________________________________________
Address: ______________________________City/State/Zip: _______________________________
Return forms to:
Community Behavioral Health
Phone: (605) 773-3123
Kneip Building
Fax: (605) 773-7076
700 Governors Drive Pierre,
Toll Free: 1- 855-878-6057
South Dakota 57501
Email: DSSBHINDMED@state.sd.us
CLEAR FORM
PRINT FOR MAILING
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical