SD EForm - 1076 V2
MEDICAL ASSISTANCE MANAGED CARE PROVIDER SELECTION FORM
 

State Office Use Only


Benefit Specialist:         Case Name:
Case Number:                    County:       
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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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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:  
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