SD EForm - 1076 V2
MEDICAL ASSISTANCE MANAGED CARE PROVIDER SELECTION FORM
State Office Use Only
Benefit Specialist:
Case Name:
Case Number:
County:
Minnehaha
Aurora
Beadle
Bennett
Bon Homme
Brookings
Brown
Brule
Buffalo
Butte
Campbell
Charles Mix
Clark
Clay
Codington
Corson
Custer
Davison
Day
Deuel
Dewey
Douglas
Edmunds
Fall River
Faulk
Grant
Gregory
Haakon
Hamlin
Hand
Hanson
Harding
Hughes
Hutchinson
Hyde
Jackson
Jerauld
Jones
Kingsbury
Lake
Lawrence
Lincoln
Lyman
McCook
McPherson
Marshall
Meade
Mellette
Miner
Moody
Pennington
Perkins
Potter
Roberts
Sanborn
Spink
Stanley
Sully
Tripp
Turner
Union
Walworth
Yankton
Ziebach
Shannon
Todd
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You and (or) your family members have just become eligible for Medical Assistance and are required to
participate in managed care. Please take the time to read and understand the information given to you by the
local office and complete the form below. You need to select a Primary Care Provider from the provider list.
Contact your local Department of Social Services office if you want to select a provider from outside your geographical area.
NOTE:
All managed Care eligible family members do not have to choose the same Primary Care Provider.
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I understand that I MUST choose one Primary Care Provider for each eligible managed care family member by completing the section below AND returning the completed form to the Department of Social Services.
If I do not choose a Primary Care Provider, the State Office of Medical Services will choose a Primary Care Provider for me and all other managed care eligible family members.
I understand that I may change my Primary Care Provider selection within 90 days, at my next annual redetermination of eligibility, or if I move to another county
Please complete this Selection form within TEN days and submit online or mail to Medical Services, Pierre, SD.
MANAGED CARE RECIPIENT'S NAME
(Family members eligible for Medical Assistance)
RECIPIENT ID NUMBER
(if known)
PRIMARY CARE PROVIDER NAME
(from Provider list)
PROVIDER ID #
(from list)
0
1
2
3
4
5
6
7
8
9
I understand the Medical Assistance Managed Care Program rules and requirements and also understand that by not following those rules and requirements I may be responsible for payment of medical bills. Refer to the
Medical Assistance Program Recipient Handbook
for more information
Signature:
Date:
Telephone Number:
Warning: When submitting this form online, please note that the form has not been sent until you receive a message in red that the form has been submitted. So please make sure you click Submit Form Online until you receive that message before you exit this form. Thank you.