SD EForm - 1076 V2
MEDICAL ASSISTANCE MANAGED CARE
PROVIDER SELECTION FORM
State Office Use Only
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.
All Managed Care eligible family members do not have to choose the same Primary
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
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.
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.